Provider Demographics
NPI:1346751344
Name:RAINES, SHANNON SHAVONNE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:SHAVONNE
Last Name:RAINES
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 1:1565 COUNTY ROAD 1480
Mailing Address - Street 2:
Mailing Address - City:NINNEKAH
Mailing Address - State:OK
Mailing Address - Zip Code:73067-4021
Mailing Address - Country:US
Mailing Address - Phone:405-222-9898
Mailing Address - Fax:
Practice Address - Street 1:909 ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-5229
Practice Address - Country:US
Practice Address - Phone:405-351-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
OK172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker