Provider Demographics
NPI:1043781487
Name:FUNKHOUSER, SHANNON (ND)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:FUNKHOUSER
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BROOKHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-1806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 BROOKHAVEN DR
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-1806
Practice Address - Country:US
Practice Address - Phone:617-571-2370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-11
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT637175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath