Healthcare Provider Details

I. General information

NPI: 1710033782
Provider Name (Legal Business Name): MARY THERESE MARCY ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7122 SE SHORT RD
GRESHAM OR
97080-9094
US

IV. Provider business mailing address

7122 SE SHORT RD
GRESHAM OR
97080-9094
US

V. Phone/Fax

Practice location:
  • Phone: 503-663-7172
  • Fax:
Mailing address:
  • Phone: 503-663-7172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP30007622
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number078040195ANPPP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: