Healthcare Provider Details

I. General information

NPI: 1982307666
Provider Name (Legal Business Name): MALLORY MARIE SOMERVILLE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2023
Last Update Date: 03/23/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 15TH AVE SE
PUYALLUP WA
98372-3715
US

IV. Provider business mailing address

6407 83RD AVENUE CT W
UNIVERSITY PLACE WA
98467-3904
US

V. Phone/Fax

Practice location:
  • Phone: 253-697-1617
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WX0800X
TaxonomyOrthopedic Registered Nurse
License NumberRN60788778
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code163WI0600X
TaxonomyInfection Control Registered Nurse
License NumberRN60788778
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60788778
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN60788778
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: