Provider Demographics
NPI:1184998734
Name:MAGDA, SHANNON L (LMP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:MAGDA
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12606 N FLORIDA ST
Mailing Address - Street 2:
Mailing Address - City:MEAD
Mailing Address - State:WA
Mailing Address - Zip Code:99021-9227
Mailing Address - Country:US
Mailing Address - Phone:509-688-3856
Mailing Address - Fax:509-459-0686
Practice Address - Street 1:308 W 1ST AVE STE 207
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-6002
Practice Address - Country:US
Practice Address - Phone:509-688-3856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-29
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60210852225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist