Provider Demographics
NPI:1801624325
Name:BLY, ANGELA JO (RN)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:JO
Last Name:BLY
Suffix:
Gender:F
Credentials:RN
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 986
Mailing Address - Street 2:
Mailing Address - City:WAITSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:99361-0986
Mailing Address - Country:US
Mailing Address - Phone:509-520-1295
Mailing Address - Fax:
Practice Address - Street 1:380 CHASE AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2924
Practice Address - Country:US
Practice Address - Phone:509-897-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-25
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00117495163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health