Provider Demographics
NPI:1033451778
Name:CADDELL, SHONNA R (LMT)
Entity Type:Individual
Prefix:
First Name:SHONNA
Middle Name:R
Last Name:CADDELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9250 EAGLE RANCH RD NW
Mailing Address - Street 2:APT #412-S
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-6033
Mailing Address - Country:US
Mailing Address - Phone:505-259-1503
Mailing Address - Fax:
Practice Address - Street 1:9250 EAGLE RANCH RD NW
Practice Address - Street 2:APT #412-S
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-6033
Practice Address - Country:US
Practice Address - Phone:505-259-1503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-20
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7556225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist