Provider Demographics
NPI:1235434341
Name:DEBOLT, BRENT M (LPN)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:M
Last Name:DEBOLT
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2314 E 13TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-4122
Mailing Address - Country:US
Mailing Address - Phone:503-709-7122
Mailing Address - Fax:
Practice Address - Street 1:2314 E 13TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-4122
Practice Address - Country:US
Practice Address - Phone:503-709-7122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-20
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP60203433164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse