Provider Demographics
NPI:1376278515
Name:BROWN, SHANNON LEANN
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:LEANN
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:SHANNON
Other - Middle Name:LEANN
Other - Last Name:FONTES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:150 SHOUP AVENUE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402
Mailing Address - Country:US
Mailing Address - Phone:208-528-4062
Mailing Address - Fax:208-528-4076
Practice Address - Street 1:150 SHOUP AVENUE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402
Practice Address - Country:US
Practice Address - Phone:208-528-4062
Practice Address - Fax:208-528-4076
Is Sole Proprietor?:No
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist