=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457958530
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | METTA WELLNESS NW PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2020
-----------------------------------------------------
Last Update Date | 01/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 904 W RIVERSIDE AVE UNIT 1107
-----------------------------------------------------
City | SPOKANE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99210-0329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-255-3527
-----------------------------------------------------
Fax | 858-947-2017
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 904 W RIVERSIDE AVE UNIT 1107
-----------------------------------------------------
City | SPOKANE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99210-0329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-255-3527
-----------------------------------------------------
Fax | 858-947-2017
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER
-----------------------------------------------------
Name | DR. BRENDAN GORDON TENNEFOSS
-----------------------------------------------------
Credential | DNP,AGPCNP-BC,ACHPN
-----------------------------------------------------
Telephone | 509-639-3394
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------