Provider Demographics
NPI:1780678292
Name:DAVIS, MARY ELIZABETH (NP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELIZABETH
Last Name:DAVIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2145 BOYER AVE E
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98112-2114
Mailing Address - Country:US
Mailing Address - Phone:206-325-2819
Mailing Address - Fax:
Practice Address - Street 1:COUNTRY DOCTOR COMMUNITY CLINIC
Practice Address - Street 2:500 19TH AVENUE EAST
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-2114
Practice Address - Country:US
Practice Address - Phone:206-299-1600
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP 30000088363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9600859Medicaid