Provider Demographics
NPI:1447790472
Name:BUKOVAC, KENDRA (MT)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:BUKOVAC
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 DALTON LN
Mailing Address - Street 2:
Mailing Address - City:ZILLAH
Mailing Address - State:WA
Mailing Address - Zip Code:98953-9309
Mailing Address - Country:US
Mailing Address - Phone:360-829-7951
Mailing Address - Fax:
Practice Address - Street 1:1033 N TACOMA AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98403-2928
Practice Address - Country:US
Practice Address - Phone:253-474-9670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-23
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60408092225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist