Provider Demographics
NPI:1487497061
Name:JOHANNSEN, SHELLISE JAN MARIE (LMT)
Entity type:Individual
Prefix:MS
First Name:SHELLISE
Middle Name:JAN MARIE
Last Name:JOHANNSEN
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 1:2790 NE STRAND RD
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98311
Mailing Address - Country:US
Mailing Address - Phone:360-940-0390
Mailing Address - Fax:
Practice Address - Street 1:2414 NW MYHRE RD #120 SILVERDALE WA. BUTTON CHIROPRACTI
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383
Practice Address - Country:US
Practice Address - Phone:360-692-2273
Practice Address - Fax:360-307-7256
Is Sole Proprietor?:No
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61177545225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist