Provider Demographics
NPI:1891530564
Name:SHELLMAN, MALISA
Entity type:Individual
Prefix:
First Name:MALISA
Middle Name:
Last Name:SHELLMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6306 E SARAZEN ST SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98513-8301
Mailing Address - Country:US
Mailing Address - Phone:360-688-0277
Mailing Address - Fax:
Practice Address - Street 1:9500 FRONT ST S STE 100
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-9415
Practice Address - Country:US
Practice Address - Phone:253-393-2483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-26
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP61220017164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse