Provider Demographics
NPI:1710518485
Name:DEMITER, SHANNON (IBCLC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:DEMITER
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24928 OLD PIPELINE RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-9681
Mailing Address - Country:US
Mailing Address - Phone:253-350-5123
Mailing Address - Fax:
Practice Address - Street 1:24928 OLD PIPELINE RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-9681
Practice Address - Country:US
Practice Address - Phone:253-350-5123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-30
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAL109189174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Single Specialty