Provider Demographics
NPI:1154675049
Name:BOSCH-GRAVEL, DEBORAH ANN
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:ANN
Last Name:BOSCH-GRAVEL
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:DEBORAH
Other - Middle Name:ANN
Other - Last Name:BOSCH-GRAVEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:15675 AMBAUM BLVD SW
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-2523
Mailing Address - Country:US
Mailing Address - Phone:206-433-2413
Mailing Address - Fax:
Practice Address - Street 1:15675 AMBAUM BLVD SW
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-2523
Practice Address - Country:US
Practice Address - Phone:206-433-2413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP00024059164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse