Healthcare Provider Details

I. General information

NPI: 1336291616
Provider Name (Legal Business Name): SHELLEY K. VESSEY P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 09/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12033 SE 256TH ST
KENT WA
98030-6503
US

IV. Provider business mailing address

PO BOX 34584
SEATTLE WA
98124-1584
US

V. Phone/Fax

Practice location:
  • Phone: 253-373-3711
  • Fax:
Mailing address:
  • Phone: 509-241-7349
  • Fax: 509-241-7628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberPT00009803
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: