Provider Demographics
NPI:1346401957
Name:DIXON, SHAUNTAE MARIE
Entity Type:Individual
Prefix:MRS
First Name:SHAUNTAE
Middle Name:MARIE
Last Name:DIXON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:SHAUNTAE
Other - Middle Name:MARIE
Other - Last Name:DELOACH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:23191 LAWRENCE ST
Mailing Address - Street 2:23191 LAWRENCE ST
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-5250
Mailing Address - Country:US
Mailing Address - Phone:574-234-3107
Mailing Address - Fax:574-234-3107
Practice Address - Street 1:23191 LAWRENCE ST
Practice Address - Street 2:23191 LAWRENCE ST
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-5250
Practice Address - Country:US
Practice Address - Phone:574-234-3107
Practice Address - Fax:574-234-3107
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN343900000X343900000X
IN1728808343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)