Provider Demographics
NPI:1801127196
Name:BUSHNELL, KELLI MARIE (LMP)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:MARIE
Last Name:BUSHNELL
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 1:10700 NE 65TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-5388
Mailing Address - Country:US
Mailing Address - Phone:360-904-1598
Mailing Address - Fax:
Practice Address - Street 1:235 NE 6TH AVE
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-2033
Practice Address - Country:US
Practice Address - Phone:360-834-5126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-26
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA173C00000X
WAMA60133151225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist