Provider Demographics
NPI:1134317803
Name:BOONE, NELLIE LUCILLE (PA)
Entity Type:Individual
Prefix:
First Name:NELLIE
Middle Name:LUCILLE
Last Name:BOONE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:NELLIE
Other - Middle Name:LUCILLE
Other - Last Name:SEABRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:500 E WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:CHEWELAH
Mailing Address - State:WA
Mailing Address - Zip Code:99109-9523
Mailing Address - Country:US
Mailing Address - Phone:509-935-8211
Mailing Address - Fax:509-935-5257
Practice Address - Street 1:500 E WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:CHEWELAH
Practice Address - State:WA
Practice Address - Zip Code:99109-9523
Practice Address - Country:US
Practice Address - Phone:509-935-8211
Practice Address - Fax:509-935-5257
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WATA10005278363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00450010OtherRAIL ROAD MEDICARE
WAP00450010OtherRAIL ROAD MEDICARE
WAG8868572Medicare PIN