Healthcare Provider Details

I. General information

NPI: 1760104541
Provider Name (Legal Business Name): MARY SUSAN HEWANKORN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY SUE HEWANKORN RN

II. Dates (important events)

Enumeration Date: 09/16/2022
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 W GARDNER AVE
SPOKANE WA
99201-2059
US

IV. Provider business mailing address

14909 S CARSTENS RD
EDWALL WA
99008-9611
US

V. Phone/Fax

Practice location:
  • Phone: 509-503-6010
  • Fax:
Mailing address:
  • Phone: 509-290-7434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60107276
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: