Provider Demographics
NPI:1154668309
Name:BLIVEN DUNHAM, REBECCA LYNN (LMP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
Last Name:BLIVEN DUNHAM
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 1:9633 MARKET PL
Mailing Address - Street 2:#103
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-7944
Mailing Address - Country:US
Mailing Address - Phone:425-335-0300
Mailing Address - Fax:
Practice Address - Street 1:9633 MARKET PL
Practice Address - Street 2:#103
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-7944
Practice Address - Country:US
Practice Address - Phone:425-335-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-08
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60245105174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist