Basic Information
| Provider Information | |||||||||
| NPI: | 1972148344 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAKE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | SALMON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3857 MARTIN WAY E | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985065268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607047170 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 205 8TH ST | ||||||||
| Address2: | |||||||||
| City: | HOQUIAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985502507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605328629 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2019 | ||||||||
| LastUpdateDate: | 11/08/2019 | ||||||||
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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 | 163W00000X | RN60956917 | WA | Y | Nursing Service Providers | Registered Nurse |
No ID Information.