Provider Demographics
NPI:1821706508
Name:SHANNON, ALEXANDRIA NICOLE
Entity Type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:NICOLE
Last Name:SHANNON
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:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72757-0130
Mailing Address - Country:US
Mailing Address - Phone:479-856-6397
Mailing Address - Fax:479-856-6412
Practice Address - Street 1:2210 MAIN DR
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-6802
Practice Address - Country:US
Practice Address - Phone:479-856-6397
Practice Address - Fax:479-856-6412
Is Sole Proprietor?:No
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist