Provider Demographics
NPI:1922238773
Name:SHAYLOR, MARISSA MILLER (LMT)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:MILLER
Last Name:SHAYLOR
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19365 SW 65TH AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-9196
Mailing Address - Country:US
Mailing Address - Phone:503-486-5199
Mailing Address - Fax:503-486-5190
Practice Address - Street 1:19365 SW 65TH AVE STE 104
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-9196
Practice Address - Country:US
Practice Address - Phone:503-486-5199
Practice Address - Fax:503-486-5190
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR9076006174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR9076006OtherLICENSE