Provider Demographics
NPI:1477377067
Name:DYE, SHANNON (LMT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:DYE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 N 6TH ST STE 415
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5995
Mailing Address - Country:US
Mailing Address - Phone:208-922-7030
Mailing Address - Fax:
Practice Address - Street 1:223 N 6TH ST STE 415
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5995
Practice Address - Country:US
Practice Address - Phone:208-922-7030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X, 372500000X, 376J00000X
IDMAS-3124225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No374U00000XNursing Service Related ProvidersHome Health Aide
No372500000XNursing Service Related ProvidersChore Provider
No376J00000XNursing Service Related ProvidersHomemaker