Provider Demographics
NPI:1558788117
Name:DEZONIA, SHANNON (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:DEZONIA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1720 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-3400
Mailing Address - Country:US
Mailing Address - Phone:817-453-5912
Mailing Address - Fax:
Practice Address - Street 1:1720 E BROAD ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-3400
Practice Address - Country:US
Practice Address - Phone:817-453-5912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-20
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX771109363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily