Provider Demographics
NPI:1861867277
Name:DARNELL, SHANE
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:
Last Name:DARNELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 BERRETT AVE
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-1201
Mailing Address - Country:US
Mailing Address - Phone:208-529-6148
Mailing Address - Fax:208-529-7061
Practice Address - Street 1:449 BERRETT AVE
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274-1201
Practice Address - Country:US
Practice Address - Phone:208-529-6148
Practice Address - Fax:208-529-7061
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID11246ZE0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0500XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherEEG