Provider Demographics
NPI:1396029542
Name:PETTIS, BRANDIE MARIE (LMP)
Entity Type:Individual
Prefix:MRS
First Name:BRANDIE
Middle Name:MARIE
Last Name:PETTIS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 N LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-2138
Mailing Address - Country:US
Mailing Address - Phone:509-252-9890
Mailing Address - Fax:
Practice Address - Street 1:1105 N LINCOLN ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2138
Practice Address - Country:US
Practice Address - Phone:509-252-9890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60026380225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist