Provider Demographics
NPI:1447216502
Name:WYRWITZKE, SHANNON L (LMP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:WYRWITZKE
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 1:2310 MILDRED ST W
Mailing Address - Street 2:SUITE 130
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-6036
Mailing Address - Country:US
Mailing Address - Phone:253-460-4244
Mailing Address - Fax:877-841-5137
Practice Address - Street 1:2310 MILDRED ST W
Practice Address - Street 2:STE 130
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-6031
Practice Address - Country:US
Practice Address - Phone:253-460-4244
Practice Address - Fax:877-841-5137
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020781225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00020781OtherMASSAGE THERAPY LICENSE