Provider Demographics
NPI:1710437058
Name:WHEELWRIGHT, SHANNON MARIE (LAC)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:MARIE
Last Name:WHEELWRIGHT
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 1:35040 OAK WAY
Mailing Address - Street 2:
Mailing Address - City:JULIAN
Mailing Address - State:CA
Mailing Address - Zip Code:92036-9526
Mailing Address - Country:US
Mailing Address - Phone:862-354-1775
Mailing Address - Fax:
Practice Address - Street 1:1804 CABLE ST
Practice Address - Street 2:SUITE B
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92107-3141
Practice Address - Country:US
Practice Address - Phone:619-243-5109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 17342171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist