Provider Demographics
NPI:1265791750
Name:INGRUM, SHANNON MICHELLE (LMP)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:MICHELLE
Last Name:INGRUM
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 1:6210 209TH ST NE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98223-4253
Mailing Address - Country:US
Mailing Address - Phone:360-631-9955
Mailing Address - Fax:
Practice Address - Street 1:6210 209TH ST NE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223-4253
Practice Address - Country:US
Practice Address - Phone:360-631-9955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-03
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00016813174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist