Healthcare Provider Details

I. General information

NPI: 1336292770
Provider Name (Legal Business Name): MARIEL L PLAEGER-BROCKWAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 LILLY RD NE
OLYMPIA WA
98506-5101
US

IV. Provider business mailing address

525 LILLY RD NE
OLYMPIA WA
98506-5101
US

V. Phone/Fax

Practice location:
  • Phone: 360-493-4002
  • Fax: 360-493-5524
Mailing address:
  • Phone: 360-493-4002
  • Fax: 360-493-5524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberMD00024395
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: