Provider Demographics
NPI:1306823026
Name:HENNEFER, BROOK
Entity Type:Individual
Prefix:
First Name:BROOK
Middle Name:
Last Name:HENNEFER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18303 107TH STREET CT E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-6056
Mailing Address - Country:US
Mailing Address - Phone:253-826-6689
Mailing Address - Fax:
Practice Address - Street 1:22117 SE 237TH ST
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-8533
Practice Address - Country:US
Practice Address - Phone:425-432-1234
Practice Address - Fax:425-432-6756
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA00052418183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician