Provider Demographics
NPI:1639477243
Name:HAFNER, MARY LYNN (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LYNN
Last Name:HAFNER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:LYNN
Other - Last Name:SILLUP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 1598
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-0064
Mailing Address - Country:US
Mailing Address - Phone:425-654-2575
Mailing Address - Fax:
Practice Address - Street 1:2099 215TH PL SE
Practice Address - Street 2:
Practice Address - City:SAMMAMISH
Practice Address - State:WA
Practice Address - Zip Code:98075-9001
Practice Address - Country:US
Practice Address - Phone:425-654-2575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23246225100000X
225100000X
WA60397911225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist