Provider Demographics
NPI:1053065417
Name:PALASTHIRA, MCKAYLA PAULINE
Entity Type:Individual
Prefix:
First Name:MCKAYLA
Middle Name:PAULINE
Last Name:PALASTHIRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7704 NE 159TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-3807
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1498 SE TECH CENTER PL
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-9591
Practice Address - Country:US
Practice Address - Phone:360-448-7464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-04
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP61043893164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALP61043893OtherCREDENTIAL