Provider Demographics
NPI:1073012324
Name:BENNETT, SHANNON COLLEEN
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:COLLEEN
Last Name:BENNETT
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 1:3301 N MILLER RD # STUDIO2
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-6431
Mailing Address - Country:US
Mailing Address - Phone:602-835-8280
Mailing Address - Fax:480-739-0385
Practice Address - Street 1:3301 N MILLER RD # STUDIO2
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-6431
Practice Address - Country:US
Practice Address - Phone:602-835-8280
Practice Address - Fax:480-739-0385
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-01
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17-1680175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath