Provider Demographics
NPI:1912046772
Name:WALTER, SHANNON (LMP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WALTER
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 1:2304 14TH ST
Mailing Address - Street 2:
Mailing Address - City:ANACORTES
Mailing Address - State:WA
Mailing Address - Zip Code:98221-2053
Mailing Address - Country:US
Mailing Address - Phone:360-333-8361
Mailing Address - Fax:
Practice Address - Street 1:3810 166TH PL NE
Practice Address - Street 2:SUITE 201-A
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223-8402
Practice Address - Country:US
Practice Address - Phone:360-333-8361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00006202225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0036825OtherLABOR & INDUSTRY PROVIDER
WA5529WAOtherREGENCE BLUE SHIELD
WA3810WAOtherREGENCE BLUE SHIELD
WAMA00006202OtherMASSAGE LICENSE NUMBER