Provider Demographics
NPI:1104399773
Name:FANIEL, SHANTON L
Entity Type:Individual
Prefix:
First Name:SHANTON
Middle Name:L
Last Name:FANIEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5367 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:SODUS
Mailing Address - State:NY
Mailing Address - Zip Code:14551-9542
Mailing Address - Country:US
Mailing Address - Phone:315-576-9434
Mailing Address - Fax:
Practice Address - Street 1:5367 SOUTH ST
Practice Address - Street 2:
Practice Address - City:SODUS
Practice Address - State:NY
Practice Address - Zip Code:14551-9542
Practice Address - Country:US
Practice Address - Phone:315-576-9434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver