Provider Demographics
NPI:1710381389
Name:PUCKETT, BRIANNE (LMT)
Entity Type:Individual
Prefix:
First Name:BRIANNE
Middle Name:
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:BRIANNE
Other - Middle Name:
Other - Last Name:VREDENBURG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:5035 NE ELAM YOUNG PKWY
Mailing Address - Street 2:SUITE 500
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-6425
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5035 NE ELAM YOUNG PKWY
Practice Address - Street 2:SUITE 500
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-6425
Practice Address - Country:US
Practice Address - Phone:503-693-1151
Practice Address - Fax:503-693-1153
Is Sole Proprietor?:No
Enumeration Date:2014-10-10
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20203225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist