Healthcare Provider Details

I. General information

NPI: 1538493242
Provider Name (Legal Business Name): VANESSA G BUSH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2009
Last Update Date: 10/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9618 GRAVELLY LAKE DR SW #201
LAKEWOOD WA
98499-1575
US

IV. Provider business mailing address

3232 94TH ST S #6
LAKEWOOD WA
98499-9322
US

V. Phone/Fax

Practice location:
  • Phone: 253-777-2321
  • Fax:
Mailing address:
  • Phone: 253-777-2321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number0025013
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: