Provider Demographics
NPI:1164847075
Name:NICODEMUS, SHANNON
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:NICODEMUS
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 1:560 COHASSET RD
Mailing Address - Street 2:SUITE 175
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-2212
Mailing Address - Country:US
Mailing Address - Phone:530-891-2999
Mailing Address - Fax:
Practice Address - Street 1:560 COHASSET RD
Practice Address - Street 2:SUITE 175
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-2212
Practice Address - Country:US
Practice Address - Phone:530-891-2999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-28
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA244508164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse