Provider Demographics
NPI:1295422863
Name:KELLEY, SHANNON AIMEE (LMT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:AIMEE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8111 145TH DR SE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98290-9080
Mailing Address - Country:US
Mailing Address - Phone:425-530-0380
Mailing Address - Fax:
Practice Address - Street 1:112 AVENUE D UNIT A
Practice Address - Street 2:
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98290-2743
Practice Address - Country:US
Practice Address - Phone:360-863-2412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61423070225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist