Provider Demographics
NPI:1578271375
Name:STEVENSON, SHANNISE L
Entity Type:Individual
Prefix:
First Name:SHANNISE
Middle Name:L
Last Name:STEVENSON
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 1:5641 VISTA OAK WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95842-2264
Mailing Address - Country:US
Mailing Address - Phone:916-417-9809
Mailing Address - Fax:
Practice Address - Street 1:5641 VISTA OAK WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95842-2264
Practice Address - Country:US
Practice Address - Phone:916-417-9809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator