Provider Demographics
NPI:1568648962
Name:SHEA, MARGUERITE M
Entity Type:Individual
Prefix:
First Name:MARGUERITE
Middle Name:M
Last Name:SHEA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:888 SWIFT BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-3514
Mailing Address - Country:US
Mailing Address - Phone:509-942-2718
Mailing Address - Fax:
Practice Address - Street 1:1305 MANSFIELD ST
Practice Address - Street 2:SUITE 4
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3588
Practice Address - Country:US
Practice Address - Phone:509-942-2718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00000187133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8356180Medicaid
WA8356180Medicaid
WAGAB36051Medicare PIN