Provider Demographics
NPI:1306045380
Name:SHELBY, LISA DIANE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DIANE
Last Name:SHELBY
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 1:37547 21ST AVE S
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-7586
Mailing Address - Country:US
Mailing Address - Phone:866-824-8302
Mailing Address - Fax:866-824-8302
Practice Address - Street 1:37547 21ST AVE S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-7586
Practice Address - Country:US
Practice Address - Phone:866-824-8302
Practice Address - Fax:866-824-8302
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023626225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist