Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | MA00015786 | WA |
NPI | 1013003102 |
---|---|
Provider Name | Nichole Renenn Bortle |
First Address | Federal Way, WA 98093-1255 |
Second Address | Seatac, WA 98188-5470 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/10/2006 |
Last Update Date | 08/07/2007 |