Provider Demographics
NPI:1528567039
Name:BRONSON, BRYNNA JILL (LMT)
Entity Type:Individual
Prefix:
First Name:BRYNNA
Middle Name:JILL
Last Name:BRONSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:579 EASTSIDE CHEWUCH RD
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:WA
Mailing Address - Zip Code:98862-9735
Mailing Address - Country:US
Mailing Address - Phone:360-790-5590
Mailing Address - Fax:
Practice Address - Street 1:588 E CHEWUCH RD
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:WA
Practice Address - Zip Code:98862-9886
Practice Address - Country:US
Practice Address - Phone:360-790-5590
Practice Address - Fax:360-790-5590
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60822983225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA60822983OtherMASSAGE THERAPIST