Provider Demographics
NPI:1013494665
Name:LUNDGREN, BRONWEN (LMT,MMP)
Entity type:Individual
Prefix:MRS
First Name:BRONWEN
Middle Name:
Last Name:LUNDGREN
Suffix:
Gender:F
Credentials:LMT,MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3737 EL JOBEAN RD # L4
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33953-5611
Mailing Address - Country:US
Mailing Address - Phone:941-236-6196
Mailing Address - Fax:
Practice Address - Street 1:2975 BOBCAT VILLAGE CENTER RD UNIT 300
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34288-4604
Practice Address - Country:US
Practice Address - Phone:941-236-6196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA89184225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist