Provider Demographics
NPI:1164660627
Name:PHELAN, MARY CATHERINE (LMP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CATHERINE
Last Name:PHELAN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16500 SE 15TH ST
Mailing Address - Street 2:SUITE 160
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9665
Mailing Address - Country:US
Mailing Address - Phone:360-718-7944
Mailing Address - Fax:360-718-7931
Practice Address - Street 1:16500 SE 15TH ST
Practice Address - Street 2:SUITE 160
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-9665
Practice Address - Country:US
Practice Address - Phone:360-718-7944
Practice Address - Fax:360-718-7931
Is Sole Proprietor?:No
Enumeration Date:2009-01-21
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024639174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist