Provider Demographics
NPI:1073768339
Name:EISERT, SHANNON M (LMP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:EISERT
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 KITTITAS ST
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-3409
Mailing Address - Country:US
Mailing Address - Phone:509-264-0102
Mailing Address - Fax:
Practice Address - Street 1:630 N CHELAN AVE
Practice Address - Street 2:SUITE B-2
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-6622
Practice Address - Country:US
Practice Address - Phone:509-665-8363
Practice Address - Fax:509-662-7274
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-28
Last Update Date:2008-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00021986225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist