Provider Demographics
NPI:1639225907
Name:CARPENTER, SHANNON LARAE (LMP)
Entity Type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:LARAE
Last Name:CARPENTER
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 1:2614 M ST SE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-7765
Mailing Address - Country:US
Mailing Address - Phone:206-715-9027
Mailing Address - Fax:
Practice Address - Street 1:518 S TOBIN ST
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-1303
Practice Address - Country:US
Practice Address - Phone:206-715-9027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019843174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist