Provider Demographics
NPI:1598234718
Name:NENTWIG, SHELLY (LMT)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:NENTWIG
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 S LINDSAY RD STE 119A
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-2100
Mailing Address - Country:US
Mailing Address - Phone:480-382-1366
Mailing Address - Fax:
Practice Address - Street 1:3303 S LINDSAY RD STE 119A
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-2100
Practice Address - Country:US
Practice Address - Phone:480-382-1366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-16
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-23102225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist