Provider Demographics
NPI:1629170386
Name:WINGATE, SHAWNA T (LMP)
Entity Type:Individual
Prefix:MS
First Name:SHAWNA
Middle Name:T
Last Name:WINGATE
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 1:2410 TYNDELL CIR SW
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-6253
Mailing Address - Country:US
Mailing Address - Phone:360-250-9090
Mailing Address - Fax:360-943-1918
Practice Address - Street 1:2405 EVERGREEN PARK DR SW
Practice Address - Street 2:SUITE A-1
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-6053
Practice Address - Country:US
Practice Address - Phone:360-250-9090
Practice Address - Fax:360-943-1918
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019282225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0204507OtherDEPT. OF L&I