Provider Demographics
NPI:1043846207
Name:BOADO, KATHLEEN GAYLE TABAQUIN (NP)
Entity type:Individual
Prefix:
First Name:KATHLEEN GAYLE
Middle Name:TABAQUIN
Last Name:BOADO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26913 223RD LN SE
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-7479
Mailing Address - Country:US
Mailing Address - Phone:808-397-6119
Mailing Address - Fax:
Practice Address - Street 1:26913 223RD LN SE
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-7479
Practice Address - Country:US
Practice Address - Phone:808-397-6119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP-61050697363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily