Provider Demographics
NPI:1316286859
Name:LEE, SHANNON L (LMP)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:L
Last Name:LEE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMP
Mailing Address - Street 1:614 E SELTICE WAY STE A
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-6367
Mailing Address - Country:US
Mailing Address - Phone:208-640-1117
Mailing Address - Fax:208-777-9100
Practice Address - Street 1:614 E SELTICE WAY STE A
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-6367
Practice Address - Country:US
Practice Address - Phone:208-640-1117
Practice Address - Fax:208-777-9100
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-04
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00011066225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist