Provider Demographics
NPI:1588774004
Name:WIGHTMAN, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WIGHTMAN
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 1:14731 MAIN ST
Mailing Address - Street 2:APT G 104
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-2021
Mailing Address - Country:US
Mailing Address - Phone:425-749-7131
Mailing Address - Fax:
Practice Address - Street 1:4310 HOYT AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-2315
Practice Address - Country:US
Practice Address - Phone:425-258-2474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAOT00004218OtherLICENSE #