Provider Demographics
NPI:1477613883
Name:AVERY, SHAWNA DORENE (OTC)
Entity Type:Individual
Prefix:MR
First Name:SHAWNA
Middle Name:DORENE
Last Name:AVERY
Suffix:
Gender:F
Credentials:OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 E BRIGGSMORE AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-2707
Mailing Address - Country:US
Mailing Address - Phone:209-521-6097
Mailing Address - Fax:209-572-4579
Practice Address - Street 1:1409 E BRIGGSMORE AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2707
Practice Address - Country:US
Practice Address - Phone:209-521-6097
Practice Address - Fax:209-572-4579
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other