Healthcare Provider Details

I. General information

NPI: 1457154023
Provider Name (Legal Business Name): LICENNA MICHELLE BOUIT DUNN PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2025
Last Update Date: 03/31/2025
Certification Date: 02/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W 5TH AVE
SPOKANE WA
99204-2803
US

IV. Provider business mailing address

910 W 5TH AVE STE 900
SPOKANE WA
99204-2948
US

V. Phone/Fax

Practice location:
  • Phone: 509-603-5800
  • Fax:
Mailing address:
  • Phone: 916-622-2464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberPA.61673586
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: