Healthcare Provider Details

I. General information

NPI: 1124219035
Provider Name (Legal Business Name): DONNELLE J RODRIGUEZ PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2007
Last Update Date: 08/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 N GARRISON RD
VANCOUVER WA
98664-1313
US

IV. Provider business mailing address

16314 NE 125TH CT
BRUSH PRAIRIE WA
98606-9563
US

V. Phone/Fax

Practice location:
  • Phone: 360-694-7501
  • Fax: 360-694-8148
Mailing address:
  • Phone: 360-597-4555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number7753
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: