Provider Demographics
NPI:1992980296
Name:MCKINNEY, SHERISE AUTUMN (LMP)
Entity type:Individual
Prefix:
First Name:SHERISE
Middle Name:AUTUMN
Last Name:MCKINNEY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26723 216TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-6127
Mailing Address - Country:US
Mailing Address - Phone:425-432-4223
Mailing Address - Fax:
Practice Address - Street 1:26723 216TH AVE SE
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-6127
Practice Address - Country:US
Practice Address - Phone:425-432-4223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-04
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00016671225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist