Provider Demographics
NPI:1538493242
Name:BUSH, VANESSA G
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:G
Last Name:BUSH
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 1:3232 94TH ST S
Mailing Address - Street 2:#6
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-9322
Mailing Address - Country:US
Mailing Address - Phone:253-777-2321
Mailing Address - Fax:
Practice Address - Street 1:9618 GRAVELLY LAKE DR SW
Practice Address - Street 2:#201
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-1575
Practice Address - Country:US
Practice Address - Phone:253-777-2321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-28
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0025013247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other