Provider Demographics
NPI:1013190297
Name:STALLWORTH, SHANNON LYNN (LMT,NCTMB)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:LYNN
Last Name:STALLWORTH
Suffix:
Gender:F
Credentials:LMT,NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 LAKE LAND BLVD
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-5521
Mailing Address - Country:US
Mailing Address - Phone:217-235-3100
Mailing Address - Fax:
Practice Address - Street 1:921 LAKE LAND BLVD
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-5521
Practice Address - Country:US
Practice Address - Phone:217-235-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist