Provider Demographics
NPI:1639761133
Name:MCDONALD, SARA JERENE CHAMPOUX
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:JERENE CHAMPOUX
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:JERENE
Other - Last Name:CHAMPOUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1208 ROAD 60
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-2089
Mailing Address - Country:US
Mailing Address - Phone:360-920-4813
Mailing Address - Fax:
Practice Address - Street 1:208 N EUCLID RD
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:WA
Practice Address - Zip Code:98930-9470
Practice Address - Country:US
Practice Address - Phone:509-882-1855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61141574363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology