Basic Information
| Provider Information | |||||||||
| NPI: | 1972960227 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLAKE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | MINA | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4301 S PINE ST STE 301 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984097206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534766500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4301 S PINE ST STE 301 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984097206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534766500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2016 | ||||||||
| LastUpdateDate: | 04/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | IN PROCESS | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.