Provider Demographics
NPI:1417334699
Name:WEATHERUP, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WEATHERUP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3919 HESSMER AVE
Mailing Address - Street 2:APT 303 H
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-3251
Mailing Address - Country:US
Mailing Address - Phone:802-380-8263
Mailing Address - Fax:
Practice Address - Street 1:3919 HESSMER AVE
Practice Address - Street 2:APT 303 H
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-3251
Practice Address - Country:US
Practice Address - Phone:802-380-8263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-27
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist