Provider Demographics
NPI:1881216703
Name:SHANNON, TABITHA (RN)
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:
Last Name:SHANNON
Suffix:
Gender:F
Credentials:RN
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 7506
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92167-0506
Mailing Address - Country:US
Mailing Address - Phone:619-857-6864
Mailing Address - Fax:
Practice Address - Street 1:8910 WESTHILL RD
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:CA
Practice Address - Zip Code:92040-3617
Practice Address - Country:US
Practice Address - Phone:619-857-6864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA751974163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator