Provider Demographics
NPI:1992294078
Name:PATINA, NICOLE LEE (CDP)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LEE
Last Name:PATINA
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 E MEAD AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98903-3720
Mailing Address - Country:US
Mailing Address - Phone:509-575-8457
Mailing Address - Fax:509-453-1273
Practice Address - Street 1:1550 IRVING ST SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-6358
Practice Address - Country:US
Practice Address - Phone:360-507-8030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-04
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60601655101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACP60601655OtherCDP