Provider Demographics
NPI:1942583174
Name:SHOEMAKER, KAILEY (LMP)
Entity Type:Individual
Prefix:
First Name:KAILEY
Middle Name:
Last Name:SHOEMAKER
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 1:703 BROADWAY ST STE 650
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-3312
Mailing Address - Country:US
Mailing Address - Phone:360-600-0081
Mailing Address - Fax:
Practice Address - Street 1:703 BROADWAY ST STE 650
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-3312
Practice Address - Country:US
Practice Address - Phone:360-600-0081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60178080225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist