Provider Demographics
NPI:1659885390
Name:LEINAN, SHANTELL LEE (LMT)
Entity Type:Individual
Prefix:
First Name:SHANTELL
Middle Name:LEE
Last Name:LEINAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:SHANTELL
Other - Middle Name:LEE
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:530 BOGACHIEL WAY
Mailing Address - Street 2:
Mailing Address - City:FORKS
Mailing Address - State:WA
Mailing Address - Zip Code:98331
Mailing Address - Country:US
Mailing Address - Phone:360-374-6271
Mailing Address - Fax:360-374-2520
Practice Address - Street 1:530 BOGACHIEL WAY
Practice Address - Street 2:
Practice Address - City:FORKS
Practice Address - State:WA
Practice Address - Zip Code:98331-9120
Practice Address - Country:US
Practice Address - Phone:360-374-6271
Practice Address - Fax:360-374-2520
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-16
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015840225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1891879680OtherFACILITY NPI NUMBER