MEDICARE: MS. KIMBERLY MCCAMMON SHAVENDER DPT

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	225100000X	Physical Therapist	PT00010242	WA

General Provider Information

NPI Number	:	1144364183
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KIMBERLY MCCAMMON SHAVENDER DPT

Provider Business Mailing Address
First Line	:	205 NW 58TH ST
Second Line	:	APT B
City	:	SEATTLE
State	:	WA
Zip	:	98107-2030
Country	:	US
Telephone Number	:	206-979-8856
Fax Number	:

Provider Business Practice Location Address
First Line	:	205 NW 58TH ST
Second Line	:	APT B
City	:	SEATTLE
State	:	WA
Zip	:	98107-2030
Country	:	US
Telephone Number	:	206-979-8856
Fax Number	:

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

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	07/08/2007

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