Healthcare Provider Details

I. General information

NPI: 1780678292
Provider Name (Legal Business Name): MARY ELIZABETH DAVIS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COUNTRY DOCTOR COMMUNITY CLINIC 500 19TH AVENUE EAST
SEATTLE WA
98112-2114
US

IV. Provider business mailing address

2145 BOYER AVE E
SEATTLE WA
98112-2114
US

V. Phone/Fax

Practice location:
  • Phone: 206-299-1600
  • Fax:
Mailing address:
  • Phone: 206-325-2819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP 30000088
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: