Provider Demographics
NPI:1194367938
Name:MINNICK, SHARYN ELAINE
Entity Type:Individual
Prefix:
First Name:SHARYN
Middle Name:ELAINE
Last Name:MINNICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 NE VAIL LN
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-3933
Mailing Address - Country:US
Mailing Address - Phone:518-223-3135
Mailing Address - Fax:
Practice Address - Street 1:550 SW INDUSTRIAL WAY STE 100
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1011
Practice Address - Country:US
Practice Address - Phone:541-728-3911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-14
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR25104225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist