Provider Demographics
NPI:1376664698
Name:BISSONETTE, SHANNA LYNN (DC)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:LYNN
Last Name:BISSONETTE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 716
Mailing Address - Street 2:272 SIERRA MANOR RD 2B
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546-0716
Mailing Address - Country:US
Mailing Address - Phone:760-793-3895
Mailing Address - Fax:
Practice Address - Street 1:272 SIERRA MANOR RD
Practice Address - Street 2:2B
Practice Address - City:MAMMOTH LAKES
Practice Address - State:CA
Practice Address - Zip Code:93546-0716
Practice Address - Country:US
Practice Address - Phone:760-793-3895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 23101111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0231010Medicare PIN