Provider Demographics
NPI:1720325202
Name:LAZENBY, BREANNA RENEE (LMP)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:RENEE
Last Name:LAZENBY
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 1:6515 132ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98033-8628
Mailing Address - Country:US
Mailing Address - Phone:425-822-4326
Mailing Address - Fax:425-827-3572
Practice Address - Street 1:6515 132ND AVE NE
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-8628
Practice Address - Country:US
Practice Address - Phone:425-822-4326
Practice Address - Fax:425-827-3572
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-03
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60258449225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist