Provider Demographics
NPI:1942438387
Name:SUTTON HEIM, SHONTEL ANGEL MARIE (LMP)
Entity Type:Individual
Prefix:MRS
First Name:SHONTEL
Middle Name:ANGEL MARIE
Last Name:SUTTON HEIM
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:PO BOX 2992
Mailing Address - Street 2:
Mailing Address - City:BELFAIR
Mailing Address - State:WA
Mailing Address - Zip Code:98528
Mailing Address - Country:US
Mailing Address - Phone:360-731-5190
Mailing Address - Fax:360-275-4412
Practice Address - Street 1:131 NE ROY BOAD RD
Practice Address - Street 2:SUITE A
Practice Address - City:BELFAIR
Practice Address - State:WA
Practice Address - Zip Code:98528
Practice Address - Country:US
Practice Address - Phone:360-731-5190
Practice Address - Fax:360-275-4412
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00019030225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0180319OtherLABOR & INDUSTRIES