Provider Demographics
NPI:1326444050
Name:FISH, LMT, MMP, BRANDY (LMT, MMP)
Entity Type:Individual
Prefix:MS
First Name:BRANDY
Middle Name:
Last Name:FISH, LMT, MMP
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1785 ALEXANDRA CT
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-6684
Mailing Address - Country:US
Mailing Address - Phone:920-527-1598
Mailing Address - Fax:
Practice Address - Street 1:1785 ALEXANDRA CT
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-6684
Practice Address - Country:US
Practice Address - Phone:920-527-1598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12379-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist