Provider Demographics
NPI:1053626861
Name:SHANNON, MEREDITH LUCAS
Entity Type:Individual
Prefix:MRS
First Name:MEREDITH
Middle Name:LUCAS
Last Name:SHANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20589 W WALTON DR
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85396-3532
Mailing Address - Country:US
Mailing Address - Phone:623-243-3183
Mailing Address - Fax:
Practice Address - Street 1:20589 W WALTON DR
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85396-3532
Practice Address - Country:US
Practice Address - Phone:623-243-3183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4234225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist