Provider Demographics
NPI:1992876478
Name:WAGONBLAST, AIMEE THERESE (ARNP)
Entity type:Individual
Prefix:MS
First Name:AIMEE
Middle Name:THERESE
Last Name:WAGONBLAST
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 SANDALWOOD DR SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502
Mailing Address - Country:US
Mailing Address - Phone:360-581-2646
Mailing Address - Fax:
Practice Address - Street 1:151 NE HAMPE WAY SUITE B2-6
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532
Practice Address - Country:US
Practice Address - Phone:360-748-3049
Practice Address - Fax:360-748-2129
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007079363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health