Provider Demographics
NPI:1528318862
Name:ALTENA, MARY MARGARET
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:MARGARET
Last Name:ALTENA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4014 S 270TH ST
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-7139
Mailing Address - Country:US
Mailing Address - Phone:253-945-4015
Mailing Address - Fax:
Practice Address - Street 1:4014 S 270TH ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-7139
Practice Address - Country:US
Practice Address - Phone:253-945-4015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT 00001779174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist