Provider Demographics
NPI:1487419883
Name:BENNETT, SHANNON ELISE (LMT, CD(DONA))
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELISE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LMT, CD(DONA)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7305 RADIUS LOOP SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98513-5008
Mailing Address - Country:US
Mailing Address - Phone:302-750-4937
Mailing Address - Fax:
Practice Address - Street 1:7305 RADIUS LOOP SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98513-5008
Practice Address - Country:US
Practice Address - Phone:302-750-4937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61510001225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist