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General NPI Number Information
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NPI Number | 1659326304
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Entity Type | Individual
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Provider Name | FAWNDOVE O BRUBAKER LMT
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Gender | Female
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Dates
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Enumeration Date | 05/23/2006
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Last Update Date | 09/14/2012
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Provider Practice Location Address
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Address Line | 12514 SE 7TH ST APT B24
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City | VANCOUVER
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State | WA
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Zip | 98683-4075
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Country | US
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Telephone | 503-490-4149
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Fax |
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Provider Business Mailing Address
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Address Line | 19206 SE 1ST ST STE 118
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City | CAMAS
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State | WA
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Zip | 98607-7478
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Country | US
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Telephone | 503-490-4149
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 10892
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MA60242466
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License Number State | WA
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