Provider Demographics
NPI:1316773211
Name:DORNBUSCH, PAMELA (LMT)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:DORNBUSCH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 NW FOXGLOVE ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-1193
Mailing Address - Country:US
Mailing Address - Phone:541-297-3247
Mailing Address - Fax:
Practice Address - Street 1:1300 NE ADAMS ST STE A
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-3500
Practice Address - Country:US
Practice Address - Phone:503-474-4569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-09
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18797225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist