Provider Demographics
NPI:1740568500
Name:PROFFITT, SHALON NICOLE (LMP)
Entity Type:Individual
Prefix:
First Name:SHALON
Middle Name:NICOLE
Last Name:PROFFITT
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 1:305 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-1719
Mailing Address - Country:US
Mailing Address - Phone:509-766-8428
Mailing Address - Fax:509-766-7327
Practice Address - Street 1:305 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1719
Practice Address - Country:US
Practice Address - Phone:509-766-8428
Practice Address - Fax:509-766-7327
Is Sole Proprietor?:No
Enumeration Date:2011-07-28
Last Update Date:2011-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60131046225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0263509OtherDEPT OF LABOR & INDUSTRY