Provider Demographics
NPI:1508473398
Name:WELLER, BRYANNA LYNN
Entity Type:Individual
Prefix:
First Name:BRYANNA
Middle Name:LYNN
Last Name:WELLER
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 1:1228 58TH PL SW
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-5910
Mailing Address - Country:US
Mailing Address - Phone:425-760-4721
Mailing Address - Fax:
Practice Address - Street 1:430 SE 192ND AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-9531
Practice Address - Country:US
Practice Address - Phone:360-256-6361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-26
Last Update Date:2020-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH61061250183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist