Provider Demographics
NPI:1366319824
Name:DEMMERLY, GINA MARIE (LDO)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:DEMMERLY
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 E OLIVE ST APT 103
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-8406
Mailing Address - Country:US
Mailing Address - Phone:206-658-3786
Mailing Address - Fax:
Practice Address - Street 1:4854 RAINIER AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-1742
Practice Address - Country:US
Practice Address - Phone:206-722-3939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-20
Last Update Date:2025-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADO60240657156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty