Provider Demographics
NPI:1538293535
Name:BURGSTAHLER, CONNIE LYNN
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:LYNN
Last Name:BURGSTAHLER
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 1:4916 NE ST JOHNS RD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-2547
Mailing Address - Country:US
Mailing Address - Phone:360-903-2623
Mailing Address - Fax:
Practice Address - Street 1:4916 NE ST JOHNS RD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-2547
Practice Address - Country:US
Practice Address - Phone:360-903-2623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist