MEDICARE: MS. SHANNON LYNNE QUENZER LMP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	MA00010276	WA

General Provider Information

NPI Number	:	1013067008
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHANNON LYNNE QUENZER LMP

Provider Business Mailing Address
First Line	:	8511 GOLD WAY
Second Line	:
City	:	EVERETT
State	:	WA
Zip	:	98208-3424
Country	:	US
Telephone Number	:	425-745-9052
Fax Number	:	425-745-3372

Provider Business Practice Location Address
First Line	:	3501 SHELBY RD STE C
Second Line	:
City	:	LYNNWOOD
State	:	WA
Zip	:	98087-3599
Country	:	US
Telephone Number	:	425-745-9052
Fax Number	:	425-745-3372

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	07/08/2007

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