Provider Demographics
NPI:1306854492
Name:HARLAN-IVY, MARIE C (ARNP)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:C
Last Name:HARLAN-IVY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 SUMMITVIEW AVE
Mailing Address - Street 2:#621
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3032
Mailing Address - Country:US
Mailing Address - Phone:509-573-3448
Mailing Address - Fax:509-574-4455
Practice Address - Street 1:2501 BUSINESS LN
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901-1167
Practice Address - Country:US
Practice Address - Phone:509-575-4800
Practice Address - Fax:509-573-3400
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30003719363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9625369Medicaid
S33094Medicare UPIN
WA9625369Medicaid