Provider Demographics
NPI:1497317929
Name:PATANA, CHANEL MARIE TANGEN
Entity Type:Individual
Prefix:
First Name:CHANEL
Middle Name:MARIE TANGEN
Last Name:PATANA
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 1:172 HOLGATE LN
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-8964
Mailing Address - Country:US
Mailing Address - Phone:360-880-4955
Mailing Address - Fax:
Practice Address - Street 1:2690 NE KRESKY AVE
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-2412
Practice Address - Country:US
Practice Address - Phone:360-330-9595
Practice Address - Fax:360-330-9530
Is Sole Proprietor?:No
Enumeration Date:2019-07-04
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60974097363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2133821Medicaid