Provider Demographics
NPI:1629170386
Name:WINGATE, SHAWNA T (LMP)
Entity type:Individual
Prefix:MS
First Name:SHAWNA
Middle Name:T
Last Name:WINGATE
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 1:437 WILDCAT ST SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98503-6745
Mailing Address - Country:US
Mailing Address - Phone:360-890-2112
Mailing Address - Fax:
Practice Address - Street 1:1010 HOMANN DR SE STE B
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-2423
Practice Address - Country:US
Practice Address - Phone:360-890-2112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019282225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0204507OtherDEPT. OF L&I