Provider Demographics
NPI:1326313354
Name:TYSON, SHONNELL
Entity Type:Individual
Prefix:
First Name:SHONNELL
Middle Name:
Last Name:TYSON
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 1:132 PAINTER ST
Mailing Address - Street 2:APT #1
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-3129
Mailing Address - Country:US
Mailing Address - Phone:626-219-3059
Mailing Address - Fax:
Practice Address - Street 1:10416 LOWER AZUSA RD
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-1208
Practice Address - Country:US
Practice Address - Phone:626-652-0755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner