Provider Demographics
NPI:1194363010
Name:ANDERSON, SHANNELL RENIA
Entity Type:Individual
Prefix:
First Name:SHANNELL
Middle Name:RENIA
Last Name:ANDERSON
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 1:131 BEVERAGE HILL AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-6232
Mailing Address - Country:US
Mailing Address - Phone:240-383-7336
Mailing Address - Fax:
Practice Address - Street 1:50 REDFIELD ST STE 300
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-3653
Practice Address - Country:US
Practice Address - Phone:781-540-4227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-11
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program