Provider Demographics
NPI:1891841748
Name:BRENCICK, ANASTASIA MARIE (LMP)
Entity Type:Individual
Prefix:
First Name:ANASTASIA
Middle Name:MARIE
Last Name:BRENCICK
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:PO BOX 1503
Mailing Address - Street 2:
Mailing Address - City:LANGLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98260-1503
Mailing Address - Country:US
Mailing Address - Phone:360-221-8415
Mailing Address - Fax:
Practice Address - Street 1:919 3RD ST STE 103
Practice Address - Street 2:
Practice Address - City:LANGLEY
Practice Address - State:WA
Practice Address - Zip Code:98260-9228
Practice Address - Country:US
Practice Address - Phone:360-221-8415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00009346174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist