Provider Demographics
NPI:1689755977
Name:GRAVES, MARY KAY (NP)
Entity Type:Individual
Prefix:MS
First Name:MARY KAY
Middle Name:
Last Name:GRAVES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:425-258-3900
Mailing Address - Fax:425-258-3910
Practice Address - Street 1:4004 COLBY AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-6203
Practice Address - Country:US
Practice Address - Phone:425-317-3641
Practice Address - Fax:425-339-5429
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA324759363L00000X
WAAP60325370363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2030249Medicaid
WAG8941724Medicare PIN