Provider Demographics
NPI:1457750705
Name:MAXEY, SHONDA (LMP)
Entity Type:Individual
Prefix:
First Name:SHONDA
Middle Name:
Last Name:MAXEY
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 1:15418 MAIN ST
Mailing Address - Street 2:STE 106
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-9030
Mailing Address - Country:US
Mailing Address - Phone:425-742-6034
Mailing Address - Fax:425-742-6035
Practice Address - Street 1:15418 MAIN ST
Practice Address - Street 2:STE 106
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-9030
Practice Address - Country:US
Practice Address - Phone:425-742-6034
Practice Address - Fax:425-742-6035
Is Sole Proprietor?:No
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022321225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist