1528884707 NPI number — MISS MARY A SPRAYBERRY CO61603715

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528884707 NPI number — MISS MARY A SPRAYBERRY CO61603715

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPRAYBERRY
Provider First Name:
MARY
Provider Middle Name:
A
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
CO61603715
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528884707
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1910 4TH AVE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLYMPIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98506-4632
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-338-0600
Provider Business Mailing Address Fax Number:
360-338-0601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1905 4TH AVE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98506-4631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-338-0600
Provider Business Practice Location Address Fax Number:
360-338-0601
Provider Enumeration Date:
12/03/2024

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: 101YA0400X , with the licence number:  CO61603715 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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