Provider Demographics
NPI:1841433067
Name:COPPEDGE, BONNIE JEAN (LMP)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:JEAN
Last Name:COPPEDGE
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 1:7302 213TH PL SW APT 101
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-7626
Mailing Address - Country:US
Mailing Address - Phone:425-478-0126
Mailing Address - Fax:
Practice Address - Street 1:7302 213TH PL SW APT 101
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7626
Practice Address - Country:US
Practice Address - Phone:425-478-0126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-17
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60083535225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist