Provider Demographics
NPI:1457154023
Name:DUNN, LICENNA MICHELLE BOUIT (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:LICENNA
Middle Name:MICHELLE BOUIT
Last Name:DUNN
Suffix:
Gender:
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 W 5TH AVE STE 900
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2948
Mailing Address - Country:US
Mailing Address - Phone:916-622-2464
Mailing Address - Fax:
Practice Address - Street 1:800 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2803
Practice Address - Country:US
Practice Address - Phone:509-603-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA.616735862086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery