Provider Demographics
NPI:1497105589
Name:SHANKS, TIFFANY LEE (LMP)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:LEE
Last Name:SHANKS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:LEE
Other - Last Name:DIGUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7218 288TH ST NW
Mailing Address - Street 2:
Mailing Address - City:STANWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98292-8410
Mailing Address - Country:US
Mailing Address - Phone:425-770-8930
Mailing Address - Fax:360-657-7188
Practice Address - Street 1:11605 STATE AVE STE 111
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98271-8427
Practice Address - Country:US
Practice Address - Phone:360-657-7183
Practice Address - Fax:360-657-7188
Is Sole Proprietor?:No
Enumeration Date:2016-06-20
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60672868225700000X
WAXT60666196247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other