Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225700000X | Massage Therapist | 0351 | NM |
NPI | 1003241910 |
---|---|
Provider Name | Ms. Shannon Smith |
First Address | Las Vegas, NM 87701-5026 |
Second Address | Las Vegas, NM 87701-3427 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/09/2013 |
Last Update Date | 10/09/2013 |