Healthcare Provider Details

I. General information

NPI: 1336665959
Provider Name (Legal Business Name): MARY ELIZABETH POLHAMUS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY ELIZABETH WALTON RD

II. Dates (important events)

Enumeration Date: 08/15/2017
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24060 SE KENT KANGLEY RD STE D100
MAPLE VALLEY WA
98038-6851
US

IV. Provider business mailing address

PO BOX 34876
SEATTLE WA
98124-1876
US

V. Phone/Fax

Practice location:
  • Phone: 425-690-3522
  • Fax: 425-690-9522
Mailing address:
  • Phone: 425-690-2715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberDI60752527
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI60752527
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: