Provider Demographics
NPI:1154509578
Name:SIDELL, SHANON LEE (ND, LAC, LMT)
Entity Type:Individual
Prefix:DR
First Name:SHANON
Middle Name:LEE
Last Name:SIDELL
Suffix:
Gender:F
Credentials:ND, LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 383194
Mailing Address - Street 2:
Mailing Address - City:WAIKOLOA
Mailing Address - State:HI
Mailing Address - Zip Code:96738-3194
Mailing Address - Country:US
Mailing Address - Phone:808-960-8333
Mailing Address - Fax:877-992-6761
Practice Address - Street 1:68-1845 WAIKOLOA RD
Practice Address - Street 2:SUITE #201
Practice Address - City:WAIKOLOA
Practice Address - State:HI
Practice Address - Zip Code:96738-5584
Practice Address - Country:US
Practice Address - Phone:808-960-8333
Practice Address - Fax:877-992-6761
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-07
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI171175F00000X
HI989171100000X
175L00000X, 174H00000X
HIMAT-4731174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No171100000XOther Service ProvidersAcupuncturist
No175L00000XOther Service ProvidersHomeopath
No174H00000XOther Service ProvidersHealth Educator
No174400000XOther Service ProvidersSpecialist