Provider Demographics
NPI:1548849052
Name:ANDERSON, SHANNON HALEY
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:HALEY
Last Name:ANDERSON
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 1:142 FORTUNE DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:NV
Mailing Address - Zip Code:89403-7362
Mailing Address - Country:US
Mailing Address - Phone:435-714-9403
Mailing Address - Fax:
Practice Address - Street 1:142 FORTUNE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:NV
Practice Address - Zip Code:89403-7362
Practice Address - Country:US
Practice Address - Phone:435-714-9403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-03
Last Update Date:2021-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife