Provider Demographics
NPI:1164441648
Name:GRESHAM, ANNE MARIE (ARNP)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:MARIE
Last Name:GRESHAM
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:MARIE
Other - Last Name:NIELSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 363
Mailing Address - Street 2:
Mailing Address - City:EASTSOUND
Mailing Address - State:WA
Mailing Address - Zip Code:98245-0363
Mailing Address - Country:US
Mailing Address - Phone:360-376-6181
Mailing Address - Fax:360-376-6182
Practice Address - Street 1:1286 MOUNT BAKER RD
Practice Address - Street 2:SUITE B208
Practice Address - City:EASTSOUND
Practice Address - State:WA
Practice Address - Zip Code:98245-8931
Practice Address - Country:US
Practice Address - Phone:360-376-6181
Practice Address - Fax:360-376-6182
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00055071163WP0808X
WAAP30006672364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0192477OtherLABOR AND INDUSTRIES
WA41188600498245A002OtherTRICARE (TRIWEST)
WA725195OtherGROUP HEALTH
WA6004GROtherREGENCE BLUE SHIELD
WA6004GROtherREGENCE BLUE SHIELD
WA725195OtherGROUP HEALTH
S99698Medicare UPIN