Provider Demographics
NPI:1073754354
Name:VAN DUSEN, SHANNON
Entity Type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:
Last Name:VAN DUSEN
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 1:1254 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-5015
Mailing Address - Country:US
Mailing Address - Phone:530-889-9195
Mailing Address - Fax:530-889-9197
Practice Address - Street 1:1254 HIGH ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-5015
Practice Address - Country:US
Practice Address - Phone:530-889-9195
Practice Address - Fax:530-889-9197
Is Sole Proprietor?:No
Enumeration Date:2009-03-16
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist