Provider Demographics
NPI:1154472363
Name:MAKI, ALIDA DIANE (RN)
Entity Type:Individual
Prefix:MS
First Name:ALIDA
Middle Name:DIANE
Last Name:MAKI
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:GRAYS RIVER
Mailing Address - State:WA
Mailing Address - Zip Code:98621-9724
Mailing Address - Country:US
Mailing Address - Phone:360-465-2392
Mailing Address - Fax:
Practice Address - Street 1:15 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:GRAYS RIVER
Practice Address - State:WA
Practice Address - Zip Code:98621-9724
Practice Address - Country:US
Practice Address - Phone:360-465-2392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR098102Medicaid