Provider Demographics
NPI:1902326010
Name:SHANNON, TATANASIKA LAVONNE
Entity Type:Individual
Prefix:
First Name:TATANASIKA
Middle Name:LAVONNE
Last Name:SHANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 SOFT WINDS VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29730-7642
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:411 SOFT WINDS VILLAGE DR
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-7642
Practice Address - Country:US
Practice Address - Phone:704-264-6045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-21
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No172V00000XOther Service ProvidersCommunity Health Worker
No385H00000XRespite Care FacilityRespite Care