Provider Demographics
NPI:1407914278
Name:PAINE, SHANNON RENE (LOTR)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:RENE
Last Name:PAINE
Suffix:
Gender:F
Credentials:LOTR
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 1377
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71294
Mailing Address - Country:US
Mailing Address - Phone:318-396-1969
Mailing Address - Fax:318-396-1970
Practice Address - Street 1:107 SUMMER LANE
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71921
Practice Address - Country:US
Practice Address - Phone:318-396-1969
Practice Address - Fax:318-396-1969
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200124225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5C869Medicare ID - Type Unspecified