Provider Demographics
NPI:1801109319
Name:GRAVLIN, MERRY JAYNE (MA60160263)
Entity type:Individual
Prefix:
First Name:MERRY JAYNE
Middle Name:
Last Name:GRAVLIN
Suffix:
Gender:F
Credentials:MA60160263
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12118 WADDELL CREEK RD SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98512-5922
Mailing Address - Country:US
Mailing Address - Phone:360-951-9065
Mailing Address - Fax:
Practice Address - Street 1:12118 WADDELL CREEK RD SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98512-5922
Practice Address - Country:US
Practice Address - Phone:360-951-9065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-26
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60160263172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist