Provider Demographics
NPI:1689354466
Name:BEACH, MALLORY ROSE (ARNP)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:ROSE
Last Name:BEACH
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 1:1268 MT BAKER AVE
Mailing Address - Street 2:
Mailing Address - City:CAMANO ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98282-8439
Mailing Address - Country:US
Mailing Address - Phone:509-209-3152
Mailing Address - Fax:
Practice Address - Street 1:326 S STILLAGUAMISH AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223-1652
Practice Address - Country:US
Practice Address - Phone:360-572-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-18
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61464135363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily