Provider Demographics
NPI:1881648046
Name:COUCOULES, MARY L (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:COUCOULES
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 9TH AVE
Mailing Address - Street 2:BOX 359735
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-2420
Mailing Address - Country:US
Mailing Address - Phone:206-341-4612
Mailing Address - Fax:206-341-4614
Practice Address - Street 1:3217 41ST AVE SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116-3444
Practice Address - Country:US
Practice Address - Phone:206-937-1460
Practice Address - Fax:206-938-1990
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN0076081163W00000X
WAAP30005708367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0196408OtherL&I PIN
WA9635034Medicaid
WA4143COOtherREGENCE BLUE SHIELD PIN
WA75366UOtherREGENCE BLUE SHIELD PIN
WA0196408OtherL&I PIN
WA4143COOtherREGENCE BLUE SHIELD PIN