Provider Demographics
NPI:1982123857
Name:DOUGLAS, MARY ELIZABETH (CN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:CN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7903 170TH PL NE APT 103
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-4432
Mailing Address - Country:US
Mailing Address - Phone:302-388-8518
Mailing Address - Fax:
Practice Address - Street 1:15965 NE 85TH ST STE 102
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3593
Practice Address - Country:US
Practice Address - Phone:425-882-9065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-12
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANU60794847133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist