Basic Information
| Provider Information | |||||||||
| NPI: | 1265675508 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLY | ||||||||
| FirstName: | ELEANOR | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., M.P.H. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23320 HIGHWAY 99 | ||||||||
| Address2: | |||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980268744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256405500 | ||||||||
| FaxNumber: | 4256405520 | ||||||||
| Practice Location | |||||||||
| Address1: | 23320 HIGHWAY 99 | ||||||||
| Address2: | |||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980268744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256405500 | ||||||||
| FaxNumber: | 4256405520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2009 | ||||||||
| LastUpdateDate: | 04/26/2017 | ||||||||
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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 | 207Q00000X | ML60095637 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD60233140 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD60233140 | 01 | WA | PHYSICIAN AND SURGEON LICENSE | OTHER | 2020182 | 05 | WA | MEDICAID | G8923057 | 01 | WA | MEDICARE PTAN | OTHER | FB1581190 | 01 | WA | DEA CERTIFICATE | OTHER |