Provider Demographics
NPI:1922347301
Name:SHEPHERD, ROSE ELEANOR (LMP)
Entity Type:Individual
Prefix:MRS
First Name:ROSE
Middle Name:ELEANOR
Last Name:SHEPHERD
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 1:299 WICHMAN ST S
Mailing Address - Street 2:
Mailing Address - City:TENINO
Mailing Address - State:WA
Mailing Address - Zip Code:98589-9291
Mailing Address - Country:US
Mailing Address - Phone:360-451-1282
Mailing Address - Fax:
Practice Address - Street 1:509 CUSTER WAY SE
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-3332
Practice Address - Country:US
Practice Address - Phone:360-451-1282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60321229225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist