Provider Demographics
NPI:1508323510
Name:NIKULA, SHANNON ALYSE (SLP-A)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ALYSE
Last Name:NIKULA
Suffix:
Gender:F
Credentials:SLP-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21168 E TIERRA GRANDE DR
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-6767
Mailing Address - Country:US
Mailing Address - Phone:702-817-3160
Mailing Address - Fax:
Practice Address - Street 1:21168 E TIERRA GRANDE DR
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-6767
Practice Address - Country:US
Practice Address - Phone:702-817-3160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA112562355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD10928623OtherARIZONA DRIVER'S LICENSE