Provider Demographics
NPI:1134779804
Name:PROUTY, MINDY KAY (ARNP)
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:KAY
Last Name:PROUTY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 NW MYHRE RD FL 3
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-7662
Mailing Address - Country:US
Mailing Address - Phone:564-240-4200
Mailing Address - Fax:564-240-4299
Practice Address - Street 1:1950 NW MYHRE RD FL 3
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-7662
Practice Address - Country:US
Practice Address - Phone:564-240-4200
Practice Address - Fax:564-240-4299
Is Sole Proprietor?:No
Enumeration Date:2019-09-16
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60968793363L00000X
WAAP61005851363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2141976Medicaid