Provider Demographics
NPI:1013458660
Name:COX, SHANNON N (LMT, LE)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:N
Last Name:COX
Suffix:
Gender:F
Credentials:LMT, LE
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:N
Other - Last Name:FABRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1677 E MILES AVE
Mailing Address - Street 2:B
Mailing Address - City:HAYDEN LAKE
Mailing Address - State:ID
Mailing Address - Zip Code:83835-9154
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1677 E MILES AVE
Practice Address - Street 2:B
Practice Address - City:HAYDEN LAKE
Practice Address - State:ID
Practice Address - Zip Code:83835-9154
Practice Address - Country:US
Practice Address - Phone:208-497-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG1964225700000X
WAMA60169177225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist