Healthcare Provider Details

I. General information

NPI: 1689635567
Provider Name (Legal Business Name): PATRICIA W VANDERWILDE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2006
Last Update Date: 05/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 N HOUK RD STE 204
SPOKANE VALLEY WA
99216-1097
US

IV. Provider business mailing address

PO BOX 94645
SEATTLE WA
98124-6945
US

V. Phone/Fax

Practice location:
  • Phone: 509-922-0362
  • Fax: 509-228-9542
Mailing address:
  • Phone: 509-474-3181
  • Fax: 706-650-1034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP30006179
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: