Provider Demographics
NPI:1336968726
Name:KANGOGO, DIANA J
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:J
Last Name:KANGOGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 18TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-4140
Mailing Address - Country:US
Mailing Address - Phone:616-264-4984
Mailing Address - Fax:
Practice Address - Street 1:3436 MARY ELDER RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5050
Practice Address - Country:US
Practice Address - Phone:360-528-2590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.1678418163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse