Provider Demographics
NPI:1104817915
Name:LIVINGSTON, MARYKAY MALLINAK (CRNA)
Entity type:Individual
Prefix:MS
First Name:MARYKAY
Middle Name:MALLINAK
Last Name:LIVINGSTON
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 1:15103 102ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-7246
Mailing Address - Country:US
Mailing Address - Phone:425-488-1494
Mailing Address - Fax:
Practice Address - Street 1:5300 TALLMAN AVE NW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-3932
Practice Address - Country:US
Practice Address - Phone:206-782-2700
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30003748367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9622952Medicaid
WAS53009Medicare UPIN
WAAB18652Medicare ID - Type UnspecifiedSWEDISH PHYSICIAN ANESTHE
WA9622952Medicaid