Healthcare Provider Details

I. General information

NPI: 1417324260
Provider Name (Legal Business Name): MARY ANN G PALMER AP60586141
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2015
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2870 NE WEST DEVILS LAKE RD
LINCOLN CITY OR
97367-5127
US

IV. Provider business mailing address

PO BOX 1189
CORVALLIS OR
97339-1189
US

V. Phone/Fax

Practice location:
  • Phone: 541-994-9191
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP60586141
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: