Healthcare Provider Details

I. General information

NPI: 1023850807
Provider Name (Legal Business Name): SHANNON MARIE DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2024
Last Update Date: 06/11/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5602 176TH ST E STE G102103
PUYALLUP WA
98375-9307
US

IV. Provider business mailing address

PO BOX 257
OLYMPIA WA
98507-0257
US

V. Phone/Fax

Practice location:
  • Phone: 253-847-7646
  • Fax:
Mailing address:
  • Phone: 253-306-2881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA.00017921
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: