Provider Demographics
NPI:1164682209
Name:MEDINA, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MEDINA
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 1:11607 CLUB HOUSE PKWY
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:AR
Mailing Address - Zip Code:72730-8775
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:363 MCKNIGHT AVE
Practice Address - Street 2:
Practice Address - City:WEST FORK
Practice Address - State:AR
Practice Address - Zip Code:72774-0000
Practice Address - Country:US
Practice Address - Phone:479-839-3035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-12
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP1338235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist