Provider Demographics
NPI:1144553074
Name:NICHOLS, MARY A (LMP, CMMP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:A
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:LMP, CMMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 911
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:WA
Mailing Address - Zip Code:98050-0911
Mailing Address - Country:US
Mailing Address - Phone:425-736-7630
Mailing Address - Fax:425-391-1174
Practice Address - Street 1:195 - 1ST PLACE N.W.
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027
Practice Address - Country:US
Practice Address - Phone:425-736-7630
Practice Address - Fax:425-391-1174
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-10
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00014204172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0141608OtherDEPT. OF L & I