Provider Demographics
NPI:1467953836
Name:BUSSE, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BUSSE
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 1:4908 E LOS COYOTES DIAGONAL APT 1
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-2838
Mailing Address - Country:US
Mailing Address - Phone:530-210-4554
Mailing Address - Fax:
Practice Address - Street 1:4908 E LOS COYOTES DIAGONAL APT 1
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-2838
Practice Address - Country:US
Practice Address - Phone:530-210-4554
Practice Address - Fax:530-210-4554
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer