Healthcare Provider Details

I. General information

NPI: 1215832373
Provider Name (Legal Business Name): PAYTEN STAKKELAND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 DUPORTAIL ST APT H148
RICHLAND WA
99352-4071
US

IV. Provider business mailing address

2550 DUPORTAIL ST APT H148
RICHLAND WA
99352-4071
US

V. Phone/Fax

Practice location:
  • Phone: 509-913-9434
  • Fax:
Mailing address:
  • Phone: 509-913-9434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberRN61446210
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: