Provider Demographics
NPI:1285202705
Name:PRIDGEN, KANEETAH VELMA (MA-P)
Entity type:Individual
Prefix:
First Name:KANEETAH
Middle Name:VELMA
Last Name:PRIDGEN
Suffix:
Gender:F
Credentials:MA-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17827 18TH AVENUE CT E
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-4119
Mailing Address - Country:US
Mailing Address - Phone:253-273-0571
Mailing Address - Fax:
Practice Address - Street 1:17827 18TH AVENUE CT E
Practice Address - Street 2:
Practice Address - City:SPANAWAY
Practice Address - State:WA
Practice Address - Zip Code:98387-4119
Practice Address - Country:US
Practice Address - Phone:253-273-0571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPC60845589246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA604769510OtherUBI