Provider Demographics
NPI:1467858878
Name:MARTIN, SHAUNNA (MA60519312)
Entity Type:Individual
Prefix:
First Name:SHAUNNA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MA60519312
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12040 98TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-4290
Mailing Address - Country:US
Mailing Address - Phone:425-749-6527
Mailing Address - Fax:425-460-9170
Practice Address - Street 1:12040 98TH AVE NE
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-4290
Practice Address - Country:US
Practice Address - Phone:425-749-6527
Practice Address - Fax:425-460-9170
Is Sole Proprietor?:No
Enumeration Date:2014-11-12
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60519312225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist