Provider Demographics
NPI:1104493600
Name:TIBBS, SHAWNA (LMT)
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:TIBBS
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:PO BOX 33053
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-3053
Mailing Address - Country:US
Mailing Address - Phone:702-613-9173
Mailing Address - Fax:
Practice Address - Street 1:9913 FOUNTAIN WALK AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-3759
Practice Address - Country:US
Practice Address - Phone:702-613-9173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNVMT.9665225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty