Provider Demographics
NPI:1063582211
Name:NELSON, MARY Q
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:Q
Last Name:NELSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:Q
Other - Last Name:SHERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 731269
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-0060
Mailing Address - Country:US
Mailing Address - Phone:253-840-2313
Mailing Address - Fax:253-840-6340
Practice Address - Street 1:5605 100TH ST SW
Practice Address - Street 2:SUITE B
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-2710
Practice Address - Country:US
Practice Address - Phone:253-284-9800
Practice Address - Fax:253-284-9801
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009699225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8904739OtherCRIME VICTIMS
WA194913OtherDEPT OF LABOR & INDUSTRY
WA1542NEOtherREGENCE BLUE SHIELD
WA8419178Medicaid
WA7954671OtherAETNA
WA194913OtherDEPT OF LABOR & INDUSTRY