Provider Demographics
NPI:1912253360
Name:PETERSON, SHANNON MICHELLE (LMP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MICHELLE
Last Name:PETERSON
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 1:5227 84TH ST SW APT 8
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-2968
Mailing Address - Country:US
Mailing Address - Phone:425-232-4087
Mailing Address - Fax:
Practice Address - Street 1:11811 MUKILTEO SPEEDWAY
Practice Address - Street 2:200
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-5442
Practice Address - Country:US
Practice Address - Phone:425-381-3866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60177035225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist