Provider Demographics
NPI:1922796986
Name:BUCKWALTER, BRENNA JANE (LMT)
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:JANE
Last Name:BUCKWALTER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3452 35TH AVE W
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98199-1667
Mailing Address - Country:US
Mailing Address - Phone:303-408-2414
Mailing Address - Fax:
Practice Address - Street 1:4250 FREMONT AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-9221
Practice Address - Country:US
Practice Address - Phone:303-408-2414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61420329225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist