Healthcare Provider Details

I. General information

NPI: 1649608902
Provider Name (Legal Business Name): MARY JO WARREN RN BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2013
Last Update Date: 10/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 E 67TH ST
TACOMA WA
98404-4254
US

IV. Provider business mailing address

1616 E 67TH ST
TACOMA WA
98404-4254
US

V. Phone/Fax

Practice location:
  • Phone: 253-474-1471
  • Fax:
Mailing address:
  • Phone: 253-474-1471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number00080398
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: