Provider Demographics
NPI:1730397308
Name:O GRADY, ELISSA NOEL (LMP)
Entity type:Individual
Prefix:MS
First Name:ELISSA
Middle Name:NOEL
Last Name:O GRADY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1215
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98227-1215
Mailing Address - Country:US
Mailing Address - Phone:360-734-9525
Mailing Address - Fax:360-734-9505
Practice Address - Street 1:1810 BROADWAY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-3133
Practice Address - Country:US
Practice Address - Phone:360-734-9525
Practice Address - Fax:360-734-9505
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020840174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0219378OtherL&I