Provider Demographics
NPI:1417379348
Name:SANDERSON, SHANNON D (LPN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:D
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:D
Other - Last Name:WOLCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:13 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT MORRIS
Mailing Address - State:NY
Mailing Address - Zip Code:14510-1108
Mailing Address - Country:US
Mailing Address - Phone:585-658-9492
Mailing Address - Fax:
Practice Address - Street 1:13 GROVE ST
Practice Address - Street 2:
Practice Address - City:MOUNT MORRIS
Practice Address - State:NY
Practice Address - Zip Code:14510-1108
Practice Address - Country:US
Practice Address - Phone:585-658-9492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-12
Last Update Date:2014-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY257574-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse