Provider Demographics
NPI:1710015110
Name:FERTAKIS, DEBORAH L (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:L
Last Name:FERTAKIS
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 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:
Practice Address - Street 1:212 E CENTRAL AVE
Practice Address - Street 2:SUITE 315
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-6291
Practice Address - Country:US
Practice Address - Phone:509-465-3919
Practice Address - Fax:509-468-0705
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30006059363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9646332Medicaid
WA1154414761OtherNPI