Provider Demographics
NPI:1891333613
Name:MISS MARY COMMUNITY DEVELOPMENT
Entity Type:Organization
Organization Name:MISS MARY COMMUNITY DEVELOPMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-908-8536
Mailing Address - Street 1:1630 TRENTON AVENUE APT 10
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310
Mailing Address - Country:US
Mailing Address - Phone:360-908-8536
Mailing Address - Fax:
Practice Address - Street 1:1630 TRENTON AVENUE APT 10
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310
Practice Address - Country:US
Practice Address - Phone:360-908-8536
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISS MARY COMMUNITY DEVELOPMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-12-11
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No251V00000XAgenciesVoluntary or Charitable