Provider Demographics
NPI:1306889811
Name:TYLER, MARY JANE (RN, ARNP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:JANE
Last Name:TYLER
Suffix:
Gender:F
Credentials:RN, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4116 PUEBLO HTS
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-8963
Mailing Address - Country:US
Mailing Address - Phone:360-708-9286
Mailing Address - Fax:360-424-0549
Practice Address - Street 1:4116 PUEBLO HTS
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-8963
Practice Address - Country:US
Practice Address - Phone:360-708-9286
Practice Address - Fax:360-424-0549
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00065198163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9635491Medicaid
WAAB29639Medicare ID - Type Unspecified
WA9635491Medicaid