Basic Information
| Provider Information | |||||||||
| NPI: | 1689755977 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAVES | ||||||||
| FirstName: | MARY KAY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5127 | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982065127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252583900 | ||||||||
| FaxNumber: | 4252583910 | ||||||||
| Practice Location | |||||||||
| Address1: | 4004 COLBY AVE | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982016203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253173641 | ||||||||
| FaxNumber: | 4253395429 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 09/01/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 324759 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | AP60325370 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2030249 | 05 | WA | MEDICAID |