Provider Demographics
NPI:1811250764
Name:CARNAGHAN, MARY ELIZABETH (FNP)
Entity type:Individual
Prefix:
First Name:MARY ELIZABETH
Middle Name:
Last Name:CARNAGHAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 GAGE BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-9532
Mailing Address - Country:US
Mailing Address - Phone:509-942-3627
Mailing Address - Fax:509-627-2983
Practice Address - Street 1:1100 GOETHALS DR
Practice Address - Street 2:SUITE F
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3300
Practice Address - Country:US
Practice Address - Phone:509-942-3272
Practice Address - Fax:509-942-3273
Is Sole Proprietor?:No
Enumeration Date:2012-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201150001NP363L00000X
WAAP60697118363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1811250764Medicaid
WA2055330Medicaid
OR500646761Medicaid
WA2055330Medicaid
ORP01674175Medicare PIN
OR185982Medicare PIN