Provider Demographics
NPI:1275980146
Name:NOLAN, MANDY
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:NOLAN
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 1:4000 MADRONA DR SE
Mailing Address - Street 2:8-2
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-2701
Mailing Address - Country:US
Mailing Address - Phone:605-660-9850
Mailing Address - Fax:
Practice Address - Street 1:4000 MADRONA DR SE
Practice Address - Street 2:8-2
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-2701
Practice Address - Country:US
Practice Address - Phone:605-660-9850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other