Provider Demographics
NPI:1699000901
Name:FACKENTHALL, CHELANE R (ARNP)
Entity Type:Individual
Prefix:
First Name:CHELANE
Middle Name:R
Last Name:FACKENTHALL
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:PO BOX 34439
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1439
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 W POPLAR ST
Practice Address - Street 2:SUITE 100
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2858
Practice Address - Country:US
Practice Address - Phone:509-522-5824
Practice Address - Fax:509-522-5738
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00151745163W00000X
WAAP60111177363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1699000901Medicaid
OR500616387Medicaid
WAG8894945Medicare PIN