Provider Demographics
NPI:1770011009
Name:LIGHTNER, SHANNON H (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:H
Last Name:LIGHTNER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10530 SPOTSYLVANIA AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-2693
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10530 SPOTSYLVANIA AVE STE 102
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-2693
Practice Address - Country:US
Practice Address - Phone:540-891-4485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202007261235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist