Provider Demographics
NPI:1730699190
Name:BAYRD, SHANNA DIANE
Entity type:Individual
Prefix:
First Name:SHANNA
Middle Name:DIANE
Last Name:BAYRD
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 1:2039 S MILL AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-2137
Mailing Address - Country:US
Mailing Address - Phone:480-999-4979
Mailing Address - Fax:
Practice Address - Street 1:2039 S MILL AVE
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-2137
Practice Address - Country:US
Practice Address - Phone:480-999-4979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17-1627175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath