Healthcare Provider Details

I. General information

NPI: 1578800702
Provider Name (Legal Business Name): STACEY L AGGABAO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2013
Last Update Date: 01/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 SE BISHOP BLVD
PULLMAN WA
99163-5512
US

IV. Provider business mailing address

1265 SW LATOUR PEAK ST
PULLMAN WA
99163-5294
US

V. Phone/Fax

Practice location:
  • Phone: 509-336-7300
  • Fax:
Mailing address:
  • Phone: 360-434-8713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN00130744
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: