Provider Demographics
NPI:1518672328
Name:FORD, SHANNON (LAC)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:564 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-5423
Mailing Address - Country:US
Mailing Address - Phone:619-467-0634
Mailing Address - Fax:
Practice Address - Street 1:564 BROADWAY
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-5423
Practice Address - Country:US
Practice Address - Phone:619-467-0634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19576171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist