Provider Demographics
NPI:1063623528
Name:SHELLEY, REGGI (LMP)
Entity type:Individual
Prefix:
First Name:REGGI
Middle Name:
Last Name:SHELLEY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:
Other - Last Name:SHELLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMP
Mailing Address - Street 1:19909 BALLINGER WAY NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-1222
Mailing Address - Country:US
Mailing Address - Phone:206-271-2475
Mailing Address - Fax:
Practice Address - Street 1:19909 BALLINGER WAY NE
Practice Address - Street 2:SUITE 100
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-1222
Practice Address - Country:US
Practice Address - Phone:206-271-2475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00019961174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist