Provider Demographics
NPI:1407420599
Name:HALE, SHANNON (BSRT, EMP)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:
Last Name:HALE
Suffix:
Gender:F
Credentials:BSRT, EMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 MEADOWLANDS DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-6062
Mailing Address - Country:US
Mailing Address - Phone:336-816-3633
Mailing Address - Fax:
Practice Address - Street 1:1409 MEADOWLANDS DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-6062
Practice Address - Country:US
Practice Address - Phone:336-816-3633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date: