Provider Demographics
NPI:1750085908
Name:WOLCOTT, KEANNA (MSN, A-GNP-C)
Entity type:Individual
Prefix:
First Name:KEANNA
Middle Name:
Last Name:WOLCOTT
Suffix:
Gender:F
Credentials:MSN, A-GNP-C
Other - Prefix:
Other - First Name:KEANNA
Other - Middle Name:
Other - Last Name:ABILD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24697 E BLUE RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-5227
Mailing Address - Country:US
Mailing Address - Phone:509-944-6621
Mailing Address - Fax:
Practice Address - Street 1:16201 E INDIANA AVE STE 3100
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-2844
Practice Address - Country:US
Practice Address - Phone:509-418-9880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-29
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61426741363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health