Provider Demographics
NPI:1083104426
Name:RAGSDALE-AVILA, MIA (NP)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:RAGSDALE-AVILA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N PALM CANYON DR STE A1
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-1866
Mailing Address - Country:US
Mailing Address - Phone:760-424-5602
Mailing Address - Fax:
Practice Address - Street 1:307 W COTA ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-2265
Practice Address - Country:US
Practice Address - Phone:360-205-8001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-11
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95006729363LP0808X
WAAP61069136363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health