Provider Demographics
NPI:1225472947
Name:VEGA, SHANELLE
Entity Type:Individual
Prefix:
First Name:SHANELLE
Middle Name:
Last Name:VEGA
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 1:3188 N HWY 97 STE 118
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7561
Mailing Address - Country:US
Mailing Address - Phone:541-330-5503
Mailing Address - Fax:541-330-5462
Practice Address - Street 1:3188 N HWY 97 STE 118
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7561
Practice Address - Country:US
Practice Address - Phone:541-330-5503
Practice Address - Fax:541-330-5462
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORHAS-P-10127066237700000X
WAHA 00004532237700000X
CAHA 7573237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist