Provider Demographics
NPI:1033645049
Name:HORTON, DONNA RACHAEL (STUDENT)
Entity Type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:RACHAEL
Last Name:HORTON
Suffix:
Gender:F
Credentials:STUDENT
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:RACHAEL
Other - Last Name:BANET BEAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5299
Mailing Address - Street 2:MS: 820-5-PCO
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98415-0299
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4748 BORGEN BLVD
Practice Address - Street 2:STE G
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98332-6764
Practice Address - Country:US
Practice Address - Phone:253-530-8450
Practice Address - Fax:253-530-8451
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60767026363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2081472Medicaid