Provider Demographics
NPI:1689747271
Name:ROSS, SHAWNEE MARIE
Entity Type:Individual
Prefix:MRS
First Name:SHAWNEE
Middle Name:MARIE
Last Name:ROSS
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 1:25112 W SADDLE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:AZ
Mailing Address - Zip Code:85342-9068
Mailing Address - Country:US
Mailing Address - Phone:623-388-9865
Mailing Address - Fax:
Practice Address - Street 1:25112 W SADDLE MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:AZ
Practice Address - Zip Code:85342-9068
Practice Address - Country:US
Practice Address - Phone:623-388-9865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10949385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ048441Medicaid