Provider Demographics
NPI:1053648568
Name:WINDOM, BRENDA J (LMP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:J
Last Name:WINDOM
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 1:427 S OAK ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-2750
Mailing Address - Country:US
Mailing Address - Phone:509-846-6367
Mailing Address - Fax:509-685-9600
Practice Address - Street 1:427 S OAK ST
Practice Address - Street 2:SUITE A
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-2750
Practice Address - Country:US
Practice Address - Phone:509-846-6367
Practice Address - Fax:509-685-9600
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANOT REQUIRED173C00000X
WAMA 60114035172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
No173C00000XOther Service ProvidersReflexologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0257488OtherL&I PROVIDER