Healthcare Provider Details

I. General information

NPI: 1215278759
Provider Name (Legal Business Name): JACQUELINE MARIE FERDOWSALI A.G.A.C.N.P
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2013
Last Update Date: 04/07/2020
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 NE MOTHER JOSEPH PL STE 330
VANCOUVER WA
98664-3288
US

IV. Provider business mailing address

PO BOX 4390
CARSON CITY NV
89702-4390
US

V. Phone/Fax

Practice location:
  • Phone: 360-514-2990
  • Fax:
Mailing address:
  • Phone: 775-445-7650
  • Fax: 775-882-4206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP60879539
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPN001499
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number11330828-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: