Provider Demographics
NPI:1497978811
Name:GAGNON, ANNETTE MARIE (ARNP)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:MARIE
Last Name:GAGNON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-1908
Mailing Address - Country:US
Mailing Address - Phone:253-396-5000
Mailing Address - Fax:253-383-5548
Practice Address - Street 1:514 S 13TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-1908
Practice Address - Country:US
Practice Address - Phone:253-396-5000
Practice Address - Fax:253-383-5548
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3006074363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9634643Medicaid
WA9634643Medicaid