Provider Demographics
NPI:1043726995
Name:LIS, SHANNON LOUISE (CPNP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:LOUISE
Last Name:LIS
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 PORT OF SPAIN RD
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-3226
Mailing Address - Country:US
Mailing Address - Phone:619-628-0183
Mailing Address - Fax:619-628-0183
Practice Address - Street 1:62 PORT OF SPAIN RD
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-3226
Practice Address - Country:US
Practice Address - Phone:619-628-0183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-14
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA487112163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics