Provider Demographics
NPI:1144710211
Name:WONG, SHANNON NATHAN (RN)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:NATHAN
Last Name:WONG
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 SAN FELIPE RD
Mailing Address - Street 2:
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023-2800
Mailing Address - Country:US
Mailing Address - Phone:831-636-4020
Mailing Address - Fax:831-636-4025
Practice Address - Street 1:1131 SAN FELIPE RD
Practice Address - Street 2:
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-2800
Practice Address - Country:US
Practice Address - Phone:831-636-4020
Practice Address - Fax:831-636-4025
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA723307163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health