Provider Demographics
NPI:1407903255
Name:MOAK, SHONNA RENEE (PT)
Entity Type:Individual
Prefix:
First Name:SHONNA
Middle Name:RENEE
Last Name:MOAK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SHONNA
Other - Middle Name:RENEE
Other - Last Name:BOHLMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:33501 1ST WAY S
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6208
Mailing Address - Country:US
Mailing Address - Phone:253-838-2400
Mailing Address - Fax:253-874-1634
Practice Address - Street 1:33501 1ST WAY S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6208
Practice Address - Country:US
Practice Address - Phone:253-838-2400
Practice Address - Fax:253-874-1634
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009905225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0207948OtherDEPT OF LABOR & INDUSTRY
WA8451783OtherMEDICAID ID NUMBER
WA912117273OtherTAX ID
WA1598725798OtherGROUP NPI NUMBER
WA0207948OtherDEPT OF LABOR & INDUSTRY