Provider Demographics
NPI:1619187788
Name:WALLACE, SHAWNLY ELISE (PT)
Entity Type:Individual
Prefix:
First Name:SHAWNLY
Middle Name:ELISE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25813 68TH AVE E
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98338-7133
Mailing Address - Country:US
Mailing Address - Phone:253-820-8816
Mailing Address - Fax:
Practice Address - Street 1:4020 S 56TH ST STE 101
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-2626
Practice Address - Country:US
Practice Address - Phone:253-475-6862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00005001225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPT00005001OtherPHYSICAL THERAPY LICENSE