Provider Demographics
NPI:1033459466
Name:MOGADAM, SHANON (LVN)
Entity Type:Individual
Prefix:
First Name:SHANON
Middle Name:
Last Name:MOGADAM
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5750 N FRESNO ST
Mailing Address - Street 2:138
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-6047
Mailing Address - Country:US
Mailing Address - Phone:925-451-0723
Mailing Address - Fax:
Practice Address - Street 1:5750 N FRESNO ST
Practice Address - Street 2:138
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-6047
Practice Address - Country:US
Practice Address - Phone:925-451-0723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-21
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA254793164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse