Healthcare Provider Details

I. General information

NPI: 1669791943
Provider Name (Legal Business Name): MS. BONNIE JEWELLE LEIGLAND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. BONNIE JEWELLE BRACKEN

II. Dates (important events)

Enumeration Date: 05/25/2010
Last Update Date: 05/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3209 E 57TH AVE SUITE F
SPOKANE WA
99223-7040
US

IV. Provider business mailing address

2727 E 53RD AVE G-205
SPOKANE WA
99223-7976
US

V. Phone/Fax

Practice location:
  • Phone: 509-448-9398
  • Fax:
Mailing address:
  • Phone: 509-443-3099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 60130147
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: