Provider Demographics
NPI:1003126095
Name:TERRY, SHANNON KATHELEEN
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:KATHELEEN
Last Name:TERRY
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 1:5033 LEISURE FALLS CT
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-6263
Mailing Address - Country:US
Mailing Address - Phone:702-741-1111
Mailing Address - Fax:
Practice Address - Street 1:5033 LEISURE FALLS CT
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-6263
Practice Address - Country:US
Practice Address - Phone:702-741-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-08
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor