Healthcare Provider Details

I. General information

NPI: 1093251555
Provider Name (Legal Business Name): MS. BRIGID DIANA TIMMONS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21707 SE STARK ST
GRESHAM OR
97030-2029
US

IV. Provider business mailing address

1155 YEARSLEY DR
DOVER DE
19904-4358
US

V. Phone/Fax

Practice location:
  • Phone: 503-489-9962
  • Fax:
Mailing address:
  • Phone: 302-612-7725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT-0004103
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: