Provider Demographics
NPI:1336331636
Name:MARTIN, MARY NIELSEN (ARNP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:NIELSEN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:DENYCE
Other - Last Name:NIELSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:4634 LUHR RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98516-2391
Mailing Address - Country:US
Mailing Address - Phone:206-291-6644
Mailing Address - Fax:
Practice Address - Street 1:4634 LUHR RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98516-2391
Practice Address - Country:US
Practice Address - Phone:206-291-6644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00046125163W00000X
WAAP30007327363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse