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General NPI Number Information
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NPI Number | 1669615282
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Entity Type | Individual
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Provider Name | KIM MICHEALLE BONNER SECUNDA LMP
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Gender | Female
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Dates
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Enumeration Date | 04/13/2009
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Last Update Date | 04/14/2009
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Provider Practice Location Address
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Address Line | 286 ENCHANTED FOREST RD SUITE 201A
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City | EASTSOUND
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State | WA
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Zip | 98245
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Country | US
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Telephone | 360-376-2512
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Fax |
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Provider Business Mailing Address
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Address Line | 25 BONNIE BRAE LN
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City | EASTSOUND
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State | WA
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Zip | 98245-9699
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Country | US
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Telephone | 360-376-2510
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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 | 0000MA7736
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License Number State | WA
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