Provider Demographics
NPI:1669791943
Name:LEIGLAND, BONNIE JEWELLE
Entity type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:JEWELLE
Last Name:LEIGLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:BONNIE
Other - Middle Name:JEWELLE
Other - Last Name:BRACKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2727 E 53RD AVE
Mailing Address - Street 2:G-205
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-7976
Mailing Address - Country:US
Mailing Address - Phone:509-443-3099
Mailing Address - Fax:
Practice Address - Street 1:3209 E 57TH AVE
Practice Address - Street 2:SUITE F
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-7040
Practice Address - Country:US
Practice Address - Phone:509-448-9398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-25
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60130147225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist