1619243672 NPI number — MRS. MARY GRACE SHOWALTER CNM

Table of content: MRS. MARY GRACE SHOWALTER CNM (NPI 1619243672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619243672 NPI number — MRS. MARY GRACE SHOWALTER CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHOWALTER
Provider First Name:
MARY
Provider Middle Name:
GRACE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STRUBHAR
Provider Other First Name:
MARY
Provider Other Middle Name:
GRACE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
CNM
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1619243672
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18300 FOBERT RD NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUBBARD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97032-9772
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
971-338-3619
Provider Business Mailing Address Fax Number:
503-980-7929

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18300 FOBERT RD NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUBBARD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97032-9772
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
971-338-3619
Provider Business Practice Location Address Fax Number:
503-980-7929
Provider Enumeration Date:
03/23/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367A00000X , with the licence number:  200950056NP NMNP-PP , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)