Provider Demographics
NPI:1881206431
Name:NELSON, SHANNON MARIE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:NELSON
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 1:19 DOUBLE H FARM RD
Mailing Address - Street 2:
Mailing Address - City:PENNSBORO
Mailing Address - State:WV
Mailing Address - Zip Code:26415-6234
Mailing Address - Country:US
Mailing Address - Phone:304-904-8441
Mailing Address - Fax:
Practice Address - Street 1:19 DOUBLE H FARM RD
Practice Address - Street 2:
Practice Address - City:PENNSBORO
Practice Address - State:WV
Practice Address - Zip Code:26415-6234
Practice Address - Country:US
Practice Address - Phone:304-904-8441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant