Healthcare Provider Details

I. General information

NPI: 1073782116
Provider Name (Legal Business Name): ROXANNE MARIE BROWN LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. ROXANNE MARIE GREY

II. Dates (important events)

Enumeration Date: 02/22/2008
Last Update Date: 04/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7902 NE ST. JOHNS RD. STE 105A
VANCOUVER WA
98665
US

IV. Provider business mailing address

11407 NE 119TH STREET
VANCOUVER WA
98662
US

V. Phone/Fax

Practice location:
  • Phone: 360-909-4460
  • Fax: 360-909-4460
Mailing address:
  • Phone: 360-909-4460
  • Fax: 360-892-0376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License NumberMA00005736
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number9083
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00005736
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number9083
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: