Provider Demographics
NPI:1477332104
Name:SMITH, MARY KAY
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:KAY
Last Name:SMITH
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 1:17761 DUNBAR RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-8751
Mailing Address - Country:US
Mailing Address - Phone:360-770-3196
Mailing Address - Fax:
Practice Address - Street 1:17761 DUNBAR RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-8751
Practice Address - Country:US
Practice Address - Phone:360-770-3196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-22
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider