Provider Demographics
NPI:1265675508
Name:BLY, ELEANOR GRACE (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:ELEANOR
Middle Name:GRACE
Last Name:BLY
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23320 HIGHWAY 99
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-8744
Mailing Address - Country:US
Mailing Address - Phone:425-640-5500
Mailing Address - Fax:425-640-5520
Practice Address - Street 1:23320 HIGHWAY 99
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-8744
Practice Address - Country:US
Practice Address - Phone:425-640-5500
Practice Address - Fax:425-640-5520
Is Sole Proprietor?:No
Enumeration Date:2009-04-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML60095637207Q00000X
WAMD60233140207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD60233140OtherPHYSICIAN AND SURGEON LICENSE
WA2020182Medicaid
WAG8923057OtherMEDICARE PTAN
WAFB1581190OtherDEA CERTIFICATE