Provider Demographics
NPI:1619301868
Name:ROSS, SHANNON VEGA (LMP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:VEGA
Last Name:ROSS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4709 225TH PL SW
Mailing Address - Street 2:
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-4129
Mailing Address - Country:US
Mailing Address - Phone:408-717-0197
Mailing Address - Fax:
Practice Address - Street 1:10021 HOLMAN RD NW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98177-4920
Practice Address - Country:US
Practice Address - Phone:206-632-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-23
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60146664225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist