Provider Demographics
NPI:1396031050
Name:WILLIAMS, SHANELLE A (LMP)
Entity Type:Individual
Prefix:
First Name:SHANELLE
Middle Name:A
Last Name:WILLIAMS
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 1:111 S 340TH ST
Mailing Address - Street 2:UNIT H
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6604
Mailing Address - Country:US
Mailing Address - Phone:206-954-8974
Mailing Address - Fax:
Practice Address - Street 1:111 S 340TH ST
Practice Address - Street 2:UNIT H
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6604
Practice Address - Country:US
Practice Address - Phone:206-954-8974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-21
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60197021225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist