Provider Demographics
NPI:1558362368
Name:BODLE-SHINGU, REBECCA M (ARNP)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:M
Last Name:BODLE-SHINGU
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MRS
Other - First Name:REBECCA
Other - Middle Name:M
Other - Last Name:VOGELGESANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:877-747-2455
Mailing Address - Fax:
Practice Address - Street 1:525 LILLY RD NE
Practice Address - Street 2:PMG SW WA ST PETER FAM MED
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5101
Practice Address - Country:US
Practice Address - Phone:360-493-7230
Practice Address - Fax:360-493-4180
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30003915363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB04021Medicare ID - Type Unspecified
WAS54662Medicare UPIN
WA9620162Medicaid