Healthcare Provider Details

I. General information

NPI: 1063582211
Provider Name (Legal Business Name): MARY Q NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY Q SHERN

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5605 100TH ST SW SUITE B
LAKEWOOD WA
98499-2710
US

IV. Provider business mailing address

PO BOX 731269
PUYALLUP WA
98373-0060
US

V. Phone/Fax

Practice location:
  • Phone: 253-284-9800
  • Fax: 253-284-9801
Mailing address:
  • Phone: 253-840-2313
  • Fax: 253-840-6340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT00009699
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: