Provider Demographics
NPI:1770960890
Name:BURGESS, COREY IONE
Entity type:Individual
Prefix:MRS
First Name:COREY
Middle Name:IONE
Last Name:BURGESS
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:COREY
Other - Middle Name:IONE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8220 171ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-3924
Mailing Address - Country:US
Mailing Address - Phone:425-891-0332
Mailing Address - Fax:
Practice Address - Street 1:1845 HIGHWAY 126 STE A
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-9626
Practice Address - Country:US
Practice Address - Phone:541-590-7534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-27
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60560728225700000X
OR24788225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR24788OtherLMT
WAMA60560728OtherLMT