Provider Demographics
NPI:1568444628
Name:BACKSTROM, MARY DIANE (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:DIANE
Last Name:BACKSTROM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:DIANE
Other - Last Name:THRESHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 E COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-3354
Mailing Address - Country:US
Mailing Address - Phone:509-684-3701
Mailing Address - Fax:509-684-5817
Practice Address - Street 1:1200 E COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-3354
Practice Address - Country:US
Practice Address - Phone:509-684-3701
Practice Address - Fax:509-684-5817
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00130472163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator