Provider Demographics
NPI:1396378600
Name:WARD, SHANNON (LPN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WARD
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2395 SMOKETREE AVE N
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5876
Mailing Address - Country:US
Mailing Address - Phone:928-505-6022
Mailing Address - Fax:928-505-6039
Practice Address - Street 1:2395 SMOKETREE AVE N
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5876
Practice Address - Country:US
Practice Address - Phone:928-505-6022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-14
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP051405164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse