Provider Demographics
NPI:1093857492
Name:SHELTON, SUSAN L (LAC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:SHELTON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4814 W GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-2734
Mailing Address - Country:US
Mailing Address - Phone:623-937-9125
Mailing Address - Fax:623-937-1435
Practice Address - Street 1:4814 W GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-2734
Practice Address - Country:US
Practice Address - Phone:623-937-9125
Practice Address - Fax:623-937-1435
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0095171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist