Provider Demographics
NPI:1174164271
Name:WALDO, ABIGAIL (ATC)
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:
Last Name:WALDO
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:ALBION
Mailing Address - State:WA
Mailing Address - Zip Code:99102-0489
Mailing Address - Country:US
Mailing Address - Phone:253-737-8275
Mailing Address - Fax:
Practice Address - Street 1:410 DAIRY DR BOHLER ATHLETIC COMPLEX M4
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99164-5422
Practice Address - Country:US
Practice Address - Phone:509-335-0319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-01
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010020062255A2300X
WAA1612693242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer