Provider Demographics
NPI:1609542828
Name:BAISDEN, SHANNON NICHOLE (MA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICHOLE
Last Name:BAISDEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6130 HODGES DR
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66205-3038
Mailing Address - Country:US
Mailing Address - Phone:913-645-5675
Mailing Address - Fax:
Practice Address - Street 1:6130 HODGES DR
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:KS
Practice Address - Zip Code:66205-3038
Practice Address - Country:US
Practice Address - Phone:913-645-5675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1180234454224Y00000X
KSW46011
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist