Provider Demographics
NPI:1659980530
Name:RABOURNE, DANA
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:RABOURNE
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 1:2081 GEMSTONE DR
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-8201
Mailing Address - Country:US
Mailing Address - Phone:509-540-5518
Mailing Address - Fax:
Practice Address - Street 1:2081 GEMSTONE DR
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-8201
Practice Address - Country:US
Practice Address - Phone:509-540-5518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIR60907080390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAIR60907080OtherWASHINGTON STATE DEPARTMENT OF HEALTH