Healthcare Provider Details

I. General information

NPI: 1053065417
Provider Name (Legal Business Name): MCKAYLA PAULINE PALASTHIRA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2022
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1498 SE TECH CENTER PL
VANCOUVER WA
98683-9591
US

IV. Provider business mailing address

7704 NE 159TH AVE
VANCOUVER WA
98682-3807
US

V. Phone/Fax

Practice location:
  • Phone: 360-448-7464
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLP61043893
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: