Provider Demographics
NPI:1710193321
Name:BRANDT, NISSA (LMP)
Entity Type:Individual
Prefix:
First Name:NISSA
Middle Name:
Last Name:BRANDT
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7726 51ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-3810
Mailing Address - Country:US
Mailing Address - Phone:360-202-4669
Mailing Address - Fax:
Practice Address - Street 1:8821 51ST AVE NE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270
Practice Address - Country:US
Practice Address - Phone:360-653-3140
Practice Address - Fax:360-657-4103
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023234174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist