Healthcare Provider Details

I. General information

NPI: 1720207541
Provider Name (Legal Business Name): BONNIE JEAN GEDDES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 MAIN AVE S #201
RENTON WA
98055-2758
US

IV. Provider business mailing address

12708 13TH LN SW #D5
BURIEN WA
98146-4000
US

V. Phone/Fax

Practice location:
  • Phone: 206-240-2039
  • Fax:
Mailing address:
  • Phone: 206-240-2039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00013959
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: