Provider Demographics
NPI:1235833302
Name:SHADDON, ROSE LEE (TAXI)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:LEE
Last Name:SHADDON
Suffix:
Gender:F
Credentials:TAXI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 WILLIAMSON WAY
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-6923
Mailing Address - Country:US
Mailing Address - Phone:479-280-2132
Mailing Address - Fax:
Practice Address - Street 1:705 WILLIAMSON WAY
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-6923
Practice Address - Country:US
Practice Address - Phone:479-280-2132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR0421-016067172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver