Basic Information
| Provider Information | |||||||||
| NPI: | 1710015110 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERTAKIS | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 421 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667472455 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 212 E CENTRAL AVE | ||||||||
| Address2: | SUITE 315 | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992086291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094653919 | ||||||||
| FaxNumber: | 5094680705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 05/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP30006059 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 9646332 | 05 | WA | MEDICAID | 1154414761 | 01 | WA | NPI | OTHER |