Healthcare Provider Details

I. General information

NPI: 1780643353
Provider Name (Legal Business Name): MARY M. WEENIKE ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 09/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 S COLUMBIAN WAY MAIL STOP S-111-DERM
SEATTLE WA
98108-1532
US

IV. Provider business mailing address

1660 S COLUMBIAN WAY S-111-DERM
SEATTLE WA
98108-1532
US

V. Phone/Fax

Practice location:
  • Phone: 206-764-2305
  • Fax: 206-764-2689
Mailing address:
  • Phone: 206-764-2305
  • Fax: 206-764-2689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP30004313
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: