Provider Demographics
NPI:1477890671
Name:BRAZEE, SHANNON SHIMAKO
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:SHIMAKO
Last Name:BRAZEE
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 1:5350 MACHADO ROAD
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230
Mailing Address - Country:US
Mailing Address - Phone:310-737-9393
Mailing Address - Fax:
Practice Address - Street 1:5350 MACHADO ROAD
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230
Practice Address - Country:US
Practice Address - Phone:310-737-9393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-08
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1104004779172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker