Provider Demographics
NPI:1992015325
Name:PRIDEAUX, SHELLY ANN (LMP)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:ANN
Last Name:PRIDEAUX
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 1:1024 72ND ST E
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98404-1732
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1024 72ND ST E
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98404-1732
Practice Address - Country:US
Practice Address - Phone:253-778-3459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-19
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60179149172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist