Provider Demographics
NPI:1194868844
Name:BURGESS, MARY C (LM, CPM)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:BURGESS
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3039 PEABODY ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1740
Mailing Address - Country:US
Mailing Address - Phone:360-510-0188
Mailing Address - Fax:
Practice Address - Street 1:3039 PEABODY ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1740
Practice Address - Country:US
Practice Address - Phone:360-510-0188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1194868844176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8863669Medicare ID - Type Unspecified