Provider Demographics
NPI:1053568691
Name:PROVALENKO, BRIDGET LEA (ATC)
Entity type:Individual
Prefix:
First Name:BRIDGET
Middle Name:LEA
Last Name:PROVALENKO
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1610 GROVER ST STE B2
Mailing Address - Street 2:
Mailing Address - City:LYNDEN
Mailing Address - State:WA
Mailing Address - Zip Code:98264-1539
Mailing Address - Country:US
Mailing Address - Phone:360-354-5245
Mailing Address - Fax:360-354-7796
Practice Address - Street 1:805 W ORCHARD DR STE 2
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1759
Practice Address - Country:US
Practice Address - Phone:360-752-1575
Practice Address - Fax:360-756-0691
Is Sole Proprietor?:No
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer