Provider Demographics
NPI:1386708808
Name:MANNERY, GWYN M (ARNP)
Entity type:Individual
Prefix:
First Name:GWYN
Middle Name:M
Last Name:MANNERY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 9TH AVE
Mailing Address - Street 2:BOX 359750
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-2420
Mailing Address - Country:US
Mailing Address - Phone:206-697-1162
Mailing Address - Fax:206-744-3830
Practice Address - Street 1:325 9TH AVE
Practice Address - Street 2:BOX 359798
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-2420
Practice Address - Country:US
Practice Address - Phone:206-697-1162
Practice Address - Fax:206-744-3830
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30006701363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA25793UOtherREGENCE PIN
WA0217077OtherL&I PIN
WA9640871Medicaid
WA0217077OtherL&I PIN
Q20611Medicare UPIN