Provider Demographics
NPI:1780694299
Name:LEA, SHANNA R (LMP, CH)
Entity type:Individual
Prefix:MS
First Name:SHANNA
Middle Name:R
Last Name:LEA
Suffix:
Gender:F
Credentials:LMP, CH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98083
Mailing Address - Country:US
Mailing Address - Phone:206-313-7711
Mailing Address - Fax:
Practice Address - Street 1:60 LAKE SHORE PLZ
Practice Address - Street 2:SUITE 3
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-3716
Practice Address - Country:US
Practice Address - Phone:425-827-3250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA13199174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist