Healthcare Provider Details

I. General information

NPI: 1023401627
Provider Name (Legal Business Name): MARY DAM HARVEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2015
Last Update Date: 02/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4627 ALAMEDA AVE
UNIVERSITY PLACE WA
98466-6301
US

IV. Provider business mailing address

4627 ALAMEDA AVE
UNIVERSITY PLACE WA
98466-6301
US

V. Phone/Fax

Practice location:
  • Phone: 253-988-1253
  • Fax:
Mailing address:
  • Phone: 253-988-1253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP 60630734
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN00150813
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: