Healthcare Provider Details

I. General information

NPI: 1255528253
Provider Name (Legal Business Name): NINA BOCKHOLDT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2007
Last Update Date: 10/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19319 7TH AVE NE #100
POULSBO WA
98370-7442
US

IV. Provider business mailing address

2500 CHERRY AVE STE 203
BREMERTON WA
98310-4202
US

V. Phone/Fax

Practice location:
  • Phone: 360-598-3764
  • Fax: 360-598-3282
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00024738
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: