Provider Demographics
NPI:1366834079
Name:BRADBURN, DENAE
Entity Type:Individual
Prefix:
First Name:DENAE
Middle Name:
Last Name:BRADBURN
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 1:4804 LACEY BLVD SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-5733
Mailing Address - Country:US
Mailing Address - Phone:360-561-0171
Mailing Address - Fax:360-915-7857
Practice Address - Street 1:4804 LACEY BLVD SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-5733
Practice Address - Country:US
Practice Address - Phone:360-561-0171
Practice Address - Fax:360-915-7857
Is Sole Proprietor?:No
Enumeration Date:2015-03-04
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022858225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist