1972639417 NPI number — MARYJANE T HEALEY OD PS

Table of content: (NPI 1972639417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972639417 NPI number — MARYJANE T HEALEY OD PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARYJANE T HEALEY OD PS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1972639417
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6710 124TH PL SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SNOHOMISH
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98296-8649
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-338-9426
Provider Business Mailing Address Fax Number:
425-338-9426

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16441 NE 74TH ST
Provider Second Line Business Practice Location Address:
E 150
Provider Business Practice Location Address City Name:
REDMOND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98052-7801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-882-2020
Provider Business Practice Location Address Fax Number:
425-376-2627
Provider Enumeration Date:
02/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HEALEY
Authorized Official First Name:
MARYJANE
Authorized Official Middle Name:
T
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
425-882-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  3658 , 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)

  • Identifier: 9634HE . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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