Provider Demographics
NPI:1669722955
Name:BONNER, GAYLYNN (LMP)
Entity type:Individual
Prefix:
First Name:GAYLYNN
Middle Name:
Last Name:BONNER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 SE LEWIS ST
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-4703
Mailing Address - Country:US
Mailing Address - Phone:425-246-8754
Mailing Address - Fax:
Practice Address - Street 1:4122 FACTORIA BLVD SE STE 202
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98006-5259
Practice Address - Country:US
Practice Address - Phone:425-590-9158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60307926225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist