Provider Demographics
NPI:1871247122
Name:ANTONIO, SHANNON JOY (LPN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:JOY
Last Name:ANTONIO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SLOOP LN
Mailing Address - Street 2:
Mailing Address - City:WAREHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02571-1135
Mailing Address - Country:US
Mailing Address - Phone:508-817-1835
Mailing Address - Fax:
Practice Address - Street 1:3 SLOOP LN
Practice Address - Street 2:
Practice Address - City:WAREHAM
Practice Address - State:MA
Practice Address - Zip Code:02571-1135
Practice Address - Country:US
Practice Address - Phone:508-817-1835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN100039251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE