Provider Demographics
NPI:1770857971
Name:BLAIR, SHANNON RAE (MA 60263684)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:RAE
Last Name:BLAIR
Suffix:
Gender:F
Credentials:MA 60263684
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:POB 245
Mailing Address - Street 2:103 SE FIRST STREET
Mailing Address - City:WINLOCK
Mailing Address - State:WA
Mailing Address - Zip Code:98596
Mailing Address - Country:US
Mailing Address - Phone:360-520-0955
Mailing Address - Fax:
Practice Address - Street 1:103 SE FIRST STREET
Practice Address - Street 2:
Practice Address - City:WINLOCK
Practice Address - State:WA
Practice Address - Zip Code:98596
Practice Address - Country:US
Practice Address - Phone:360-520-0955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-06
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60263684225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist