Provider Demographics
NPI:1003241910
Name:SMITH, SHANNON (DOM, LAC, LMT)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:DOM, LAC, LMT
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:RADHA
Other - Last Name:SMITH-JORY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:2421 JESSIE LEE LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-5026
Mailing Address - Country:US
Mailing Address - Phone:505-310-3239
Mailing Address - Fax:
Practice Address - Street 1:128 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-3427
Practice Address - Country:US
Practice Address - Phone:505-310-3239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1098171100000X
NM0351225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist