Provider Demographics
NPI:1760741284
Name:DENNIS, G'ANNA
Entity Type:Individual
Prefix:
First Name:G'ANNA
Middle Name:
Last Name:DENNIS
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 1:1173 2ND ST NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-4003
Mailing Address - Country:US
Mailing Address - Phone:971-218-0607
Mailing Address - Fax:
Practice Address - Street 1:1173 2ND ST NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-4003
Practice Address - Country:US
Practice Address - Phone:971-218-0607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-04
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15129225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR15129OtherSTATE OF OREGON BOARD OF MASSAGE THERAPISTS