Provider Demographics
NPI:1760763247
Name:HAILEY, SHANNON P
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:P
Last Name:HAILEY
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 1:800 N RAINBOW BLVD
Mailing Address - Street 2:158
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-1189
Mailing Address - Country:US
Mailing Address - Phone:702-655-7466
Mailing Address - Fax:702-642-5722
Practice Address - Street 1:4440 S MARYLAND PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-7527
Practice Address - Country:US
Practice Address - Phone:702-400-6311
Practice Address - Fax:702-642-5722
Is Sole Proprietor?:No
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner