Provider Demographics
NPI:1285027201
Name:WIGGINS, SHELLEY ANITA (PTA)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:ANITA
Last Name:WIGGINS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 LEBO BLVD
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-2617
Mailing Address - Country:US
Mailing Address - Phone:360-479-1515
Mailing Address - Fax:
Practice Address - Street 1:560 LEBO BLVD
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-2617
Practice Address - Country:US
Practice Address - Phone:360-479-1515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-16
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160033195225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant