Provider Demographics
NPI:1669615282
Name:BONNER SECUNDA, KIM MICHEALLE (LMP)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:MICHEALLE
Last Name:BONNER SECUNDA
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:25 BONNIE BRAE LN
Mailing Address - Street 2:
Mailing Address - City:EASTSOUND
Mailing Address - State:WA
Mailing Address - Zip Code:98245-9699
Mailing Address - Country:US
Mailing Address - Phone:360-376-2510
Mailing Address - Fax:
Practice Address - Street 1:286 ENCHANTED FOREST RD
Practice Address - Street 2:SUITE 201A
Practice Address - City:EASTSOUND
Practice Address - State:WA
Practice Address - Zip Code:98245
Practice Address - Country:US
Practice Address - Phone:360-376-2512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-13
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0000MA7736225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist