Provider Demographics
NPI:1336649854
Name:SHI, WEN JUN WENDY (LAC)
Entity Type:Individual
Prefix:MS
First Name:WEN JUN
Middle Name:WENDY
Last Name:SHI
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:MS
Other - First Name:WEN JUN
Other - Middle Name:WENDY
Other - Last Name:DAI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:12619 PEGASUS DR
Mailing Address - Street 2:
Mailing Address - City:WILLIS
Mailing Address - State:TX
Mailing Address - Zip Code:77318-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:690 S LOOP 336 W STE 240
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-3320
Practice Address - Country:US
Practice Address - Phone:281-818-9996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-21
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC01290171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist