Provider Demographics
NPI:1013003102
Name:BORTLE, NICHOLE RENENN (LMP)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:RENENN
Last Name:BORTLE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24255
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98093-1255
Mailing Address - Country:US
Mailing Address - Phone:253-945-8354
Mailing Address - Fax:253-945-8298
Practice Address - Street 1:19800 INTERNATIONAL BLVD
Practice Address - Street 2:
Practice Address - City:SEATAC
Practice Address - State:WA
Practice Address - Zip Code:98188-5470
Practice Address - Country:US
Practice Address - Phone:253-945-8354
Practice Address - Fax:253-945-8298
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015786225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist