Provider Demographics
NPI:1285767871
Name:PAGE, BRENDA D (LMP)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:D
Last Name:PAGE
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 1:2326 GOLDFINCH ST
Mailing Address - Street 2:APT C
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-4783
Mailing Address - Country:US
Mailing Address - Phone:360-720-2595
Mailing Address - Fax:360-874-1739
Practice Address - Street 1:205 BETHEL AVE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-5215
Practice Address - Country:US
Practice Address - Phone:360-440-2590
Practice Address - Fax:360-874-1739
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00018640174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00018640OtherMASSAGE LICENSE #
WA4146S5-00OtherFULL CIRCLE ID