MEDICARE: MS. CASSANDRA J WILLBOURN RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN60328887	WA

General Provider Information

NPI Number	:	1265969612
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CASSANDRA J WILLBOURN RN

Provider Business Mailing Address
First Line	:	PO BOX 34703
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98124-1703
Country	:	US
Telephone Number	:	206-764-0502
Fax Number	:	206-764-0516

Provider Business Practice Location Address
First Line	:	905 24TH WAY SW STE A2
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98502-6033
Country	:	US
Telephone Number	:	360-742-5010
Fax Number	:	360-742-5015

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2017
Last Update Date	:	05/16/2017

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