Provider Demographics
NPI:1437426053
Name:GOULMASSIAN, SHANNON MARIE (RN, CNS)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MARIE
Last Name:GOULMASSIAN
Suffix:
Gender:F
Credentials:RN, CNS
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 10967
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0967
Mailing Address - Country:US
Mailing Address - Phone:909-796-2036
Mailing Address - Fax:
Practice Address - Street 1:1725 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1367
Practice Address - Country:US
Practice Address - Phone:909-887-6333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-28
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA536211163WD0400X
CAL-17087163WL0100X
CA1382364SP1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP1700XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPerinatal
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Multi-Specialty
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant