Provider Demographics
NPI:1952969552
Name:MOBLEY, SHAUNA NICOLE (LMT)
Entity Type:Individual
Prefix:
First Name:SHAUNA
Middle Name:NICOLE
Last Name:MOBLEY
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 1:2802 BRITTANY DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-3980
Mailing Address - Country:US
Mailing Address - Phone:907-223-4621
Mailing Address - Fax:
Practice Address - Street 1:1000 E DIMOND BLVD STE 202
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-2029
Practice Address - Country:US
Practice Address - Phone:907-349-4212
Practice Address - Fax:907-344-3381
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-30
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK141922225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK141922OtherALASKA MASSAGE THERAPY LICENSE