Provider Demographics
NPI:1124219035
Name:RODRIGUEZ, DONNELLE J (PTA)
Entity Type:Individual
Prefix:
First Name:DONNELLE
Middle Name:J
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16314 NE 125TH CT
Mailing Address - Street 2:
Mailing Address - City:BRUSH PRAIRIE
Mailing Address - State:WA
Mailing Address - Zip Code:98606-9563
Mailing Address - Country:US
Mailing Address - Phone:360-597-4555
Mailing Address - Fax:
Practice Address - Street 1:1015 N GARRISON RD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-1313
Practice Address - Country:US
Practice Address - Phone:360-694-7501
Practice Address - Fax:360-694-8148
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7753225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant