Provider Demographics
NPI:1275982886
Name:BLANK, SHANNON
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:BLANK
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 1:1382 W B AVE
Mailing Address - Street 2:
Mailing Address - City:PLAINWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49080-9685
Mailing Address - Country:US
Mailing Address - Phone:616-405-5992
Mailing Address - Fax:
Practice Address - Street 1:1382 W B AVE
Practice Address - Street 2:
Practice Address - City:PLAINWELL
Practice Address - State:MI
Practice Address - Zip Code:49080-9685
Practice Address - Country:US
Practice Address - Phone:616-405-5992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIS530765069584247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other