Provider Demographics
NPI:1134480056
Name:FLY, ANNETTE
Entity Type:Individual
Prefix:MS
First Name:ANNETTE
Middle Name:
Last Name:FLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3603
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-3603
Mailing Address - Country:US
Mailing Address - Phone:206-371-6289
Mailing Address - Fax:
Practice Address - Street 1:1300 NE GOLDIE ST
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-4832
Practice Address - Country:US
Practice Address - Phone:360-679-5590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-07
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60375338363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily