Provider Demographics
NPI:1487019220
Name:HENNINGSEN, SHANNON DIANE (PHARMD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:DIANE
Last Name:HENNINGSEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14271 CAMERON LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3280
Mailing Address - Country:US
Mailing Address - Phone:714-604-5655
Mailing Address - Fax:
Practice Address - Street 1:14271 CAMERON LN
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3280
Practice Address - Country:US
Practice Address - Phone:714-604-5655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49596183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist