Provider Demographics
NPI:1427647197
Name:CABANILLA, AGNES ESTRADA
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:ESTRADA
Last Name:CABANILLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7523 ALABAMA DR
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-2203
Mailing Address - Country:US
Mailing Address - Phone:360-258-1994
Mailing Address - Fax:
Practice Address - Street 1:7523 ALABAMA DR
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-2203
Practice Address - Country:US
Practice Address - Phone:360-258-1994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA754812311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home