Provider Demographics
NPI:1942433479
Name:JOHNSON, SHANNON ELIZABETH (LMP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:JOHNSON
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 1:328 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-1812
Mailing Address - Country:US
Mailing Address - Phone:360-794-4500
Mailing Address - Fax:360-863-7640
Practice Address - Street 1:328 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1812
Practice Address - Country:US
Practice Address - Phone:360-794-4500
Practice Address - Fax:360-863-7640
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-01
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60101470225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist