Provider Demographics
NPI:1952820540
Name:WILSON, SHAWNA (LMP)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:WILSON
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 1:1815 HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2913
Mailing Address - Country:US
Mailing Address - Phone:360-363-2636
Mailing Address - Fax:360-636-2621
Practice Address - Street 1:1815 HUDSON ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2913
Practice Address - Country:US
Practice Address - Phone:360-363-2636
Practice Address - Fax:360-636-2621
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60758414225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist