Basic Information
| Provider Information | |||||||||
| NPI: | 1063582211 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | Q | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHERN | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | Q | ||||||||
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| OtherCredential: | MPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 731269 | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983730060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538402313 | ||||||||
| FaxNumber: | 2538406340 | ||||||||
| Practice Location | |||||||||
| Address1: | 5605 100TH ST SW | ||||||||
| Address2: | SUITE B | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984992710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532849800 | ||||||||
| FaxNumber: | 2532849801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00009699 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 194913 | 01 | WA | DEPT OF LABOR & INDUSTRY | OTHER | 7954671 | 01 | WA | AETNA | OTHER | 8904739 | 01 | WA | CRIME VICTIMS | OTHER | 1542NE | 01 | WA | REGENCE BLUE SHIELD | OTHER | 8419178 | 05 | WA | MEDICAID |