Healthcare Provider Details

I. General information

NPI: 1497105589
Provider Name (Legal Business Name): TIFFANY LEE SHANKS LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIFFANY LEE DIGUE

II. Dates (important events)

Enumeration Date: 06/20/2016
Last Update Date: 07/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11605 STATE AVE STE 111
MARYSVILLE WA
98271-8427
US

IV. Provider business mailing address

7218 288TH ST NW
STANWOOD WA
98292-8410
US

V. Phone/Fax

Practice location:
  • Phone: 360-657-7183
  • Fax: 360-657-7188
Mailing address:
  • Phone: 425-770-8930
  • Fax: 360-657-7188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberXT60666196
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60672868
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: