Healthcare Provider Details

I. General information

NPI: 1972872927
Provider Name (Legal Business Name): MS. SHIVONNE MARIE WYLIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2011
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 BROADWAY ST
VANCOUVER WA
98663-3433
US

IV. Provider business mailing address

1417 NE 130TH ST
VANCOUVER WA
98685-3163
US

V. Phone/Fax

Practice location:
  • Phone: 360-470-4856
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60229724
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: