Provider Demographics
NPI:1801222088
Name:BRUNKE, AUTUMN NOEL (LMP)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:NOEL
Last Name:BRUNKE
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 1:3013 231ST LN SE
Mailing Address - Street 2:M103
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98075-8200
Mailing Address - Country:US
Mailing Address - Phone:206-892-8332
Mailing Address - Fax:
Practice Address - Street 1:3013 231ST LN SE
Practice Address - Street 2:M103
Practice Address - City:SAMMAMISH
Practice Address - State:WA
Practice Address - Zip Code:98075-8200
Practice Address - Country:US
Practice Address - Phone:206-892-8332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-19
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60395021225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist