Provider Demographics
NPI:1740334788
Name:BONNER, DANIELLE MICHELLE (LMP)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MICHELLE
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 1:2636 19TH ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-1527
Mailing Address - Country:US
Mailing Address - Phone:208-827-0092
Mailing Address - Fax:
Practice Address - Street 1:1125 NE WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99164-2302
Practice Address - Country:US
Practice Address - Phone:509-335-7492
Practice Address - Fax:509-335-2092
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023330225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist