Provider Demographics
NPI:1790832921
Name:MOAK, SHARON (LMP)
Entity Type:Individual
Prefix:MS
First Name:SHARON
Middle Name:
Last Name:MOAK
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 1:7603 NE 13TH AVE SPC 43
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98665-0449
Mailing Address - Country:US
Mailing Address - Phone:503-320-6634
Mailing Address - Fax:
Practice Address - Street 1:7603 NE 13TH AVE SPC 43
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-0449
Practice Address - Country:US
Practice Address - Phone:503-320-6634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2016-05-24
Deactivation Date:2010-08-25
Deactivation Code:
Reactivation Date:2010-12-09
Provider Licenses
StateLicense IDTaxonomies
WAMA00022584225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist