Provider Demographics
NPI:1659326304
Name:BRUBAKER, FAWNDOVE O (LMT)
Entity type:Individual
Prefix:
First Name:FAWNDOVE
Middle Name:O
Last Name:BRUBAKER
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 1:19206 SE 1ST ST
Mailing Address - Street 2:STE 118
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-7478
Mailing Address - Country:US
Mailing Address - Phone:503-490-4149
Mailing Address - Fax:
Practice Address - Street 1:12514 SE 7TH ST APT B24
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-4075
Practice Address - Country:US
Practice Address - Phone:503-490-4149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10892225700000X
WAMA60242466174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist