Provider Demographics
NPI:1386005916
Name:INNIS-GIELISSEN, SHANNON MICHELLE (CMP, AIMI, CYI)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MICHELLE
Last Name:INNIS-GIELISSEN
Suffix:
Gender:F
Credentials:CMP, AIMI, CYI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6108 JASON CT
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-6012
Mailing Address - Country:US
Mailing Address - Phone:831-419-7552
Mailing Address - Fax:
Practice Address - Street 1:6108 JASON CT
Practice Address - Street 2:
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003-6012
Practice Address - Country:US
Practice Address - Phone:831-419-7552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24270225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist