Provider Demographics
NPI:1215354725
Name:WYLAND, MARA
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:WYLAND
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 1:329B PEARL ST
Mailing Address - Street 2:
Mailing Address - City:BUCKLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98321-9641
Mailing Address - Country:US
Mailing Address - Phone:360-829-6049
Mailing Address - Fax:360-829-3388
Practice Address - Street 1:240 NORTH A STREET
Practice Address - Street 2:
Practice Address - City:BUCKLEY
Practice Address - State:WA
Practice Address - Zip Code:98321
Practice Address - Country:US
Practice Address - Phone:360-829-6049
Practice Address - Fax:360-829-3388
Is Sole Proprietor?:No
Enumeration Date:2014-03-21
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP00054892164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse