Healthcare Provider Details

I. General information

NPI: 1487707550
Provider Name (Legal Business Name): MARY ANN SMITH C.N.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 08/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 MARTIN LUTHER KING JR WAY
TACOMA WA
98405-4265
US

IV. Provider business mailing address

PO BOX 34581
SEATTLE WA
98124-1581
US

V. Phone/Fax

Practice location:
  • Phone: 253-596-3300
  • Fax:
Mailing address:
  • Phone: 509-241-7349
  • Fax: 509-241-7628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberRN00068753
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberAP30004003
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: