Provider Demographics
NPI:1821089046
Name:WHITE, MARY DIANE (MSN, ARNP, FNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:DIANE
Last Name:WHITE
Suffix:
Gender:F
Credentials:MSN, ARNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20011 BALLINGER WAY NE STE 202
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-1286
Mailing Address - Country:US
Mailing Address - Phone:425-806-8360
Mailing Address - Fax:425-250-8566
Practice Address - Street 1:20011 BALLINGER WAY NE STE 202
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-1286
Practice Address - Country:US
Practice Address - Phone:425-806-8360
Practice Address - Fax:425-250-8566
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005666363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9638322Medicaid
P17177Medicare UPIN
WA9638322Medicaid