Provider Demographics
NPI:1154036135
Name:WANJA, GRACE WAMBUI (CNA)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:WAMBUI
Last Name:WANJA
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 BROOKDALE RD E
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98445-2821
Mailing Address - Country:US
Mailing Address - Phone:253-302-4504
Mailing Address - Fax:
Practice Address - Street 1:805 BROOKDALE RD E
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98445-2821
Practice Address - Country:US
Practice Address - Phone:253-302-4504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANC60484671376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA209155501Medicaid