Provider Demographics
NPI:1730939901
Name:DICENSO, SHANNON MARY (LPN)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARY
Last Name:DICENSO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 GLENSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BLACKSTONE
Mailing Address - State:MA
Mailing Address - Zip Code:01504-1548
Mailing Address - Country:US
Mailing Address - Phone:617-201-6759
Mailing Address - Fax:
Practice Address - Street 1:12 GLENSIDE DR
Practice Address - Street 2:
Practice Address - City:BLACKSTONE
Practice Address - State:MA
Practice Address - Zip Code:01504-1548
Practice Address - Country:US
Practice Address - Phone:617-201-6759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-22
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN89314164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse