Provider Demographics
NPI:1447019971
Name:KAMINE, SHANNON J (LMT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:J
Last Name:KAMINE
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 1:4958 W LOOMIS RD
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-4857
Mailing Address - Country:US
Mailing Address - Phone:414-839-9251
Mailing Address - Fax:
Practice Address - Street 1:4958 W LOOMIS RD
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-4857
Practice Address - Country:US
Practice Address - Phone:414-839-9251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13272-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist