Provider Demographics
NPI:1831296177
Name:ICENOGLE, DEBORAH ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:ANN
Last Name:ICENOGLE
Suffix:
Gender:F
Credentials:MD
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:509-385-0610
Mailing Address - Fax:509-227-7070
Practice Address - Street 1:5011 W LOWELL AVE STE 100
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-8587
Practice Address - Country:US
Practice Address - Phone:509-299-1958
Practice Address - Fax:509-299-1070
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028918208D00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1120765Medicaid
WA8807383Medicare ID - Type Unspecified
WA1120765Medicaid