Provider Demographics
NPI:1689602377
Name:HOLMES, MARILYN TRUDEAU (ARNP)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:TRUDEAU
Last Name:HOLMES
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 1:1100 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-4209
Mailing Address - Country:US
Mailing Address - Phone:360-419-3500
Mailing Address - Fax:360-419-3515
Practice Address - Street 1:1100 S 2ND ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-4209
Practice Address - Country:US
Practice Address - Phone:360-419-3500
Practice Address - Fax:360-419-3515
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30004170364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9616632Medicaid
WAS49703Medicare UPIN
WAABO9543Medicare ID - Type Unspecified