Provider Demographics
NPI:1891060083
Name:ETHEREDGE, SHANNON KAY
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:KAY
Last Name:ETHEREDGE
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 1:399351 W 2750 RD
Mailing Address - Street 2:
Mailing Address - City:RAMONA
Mailing Address - State:OK
Mailing Address - Zip Code:74061-3349
Mailing Address - Country:US
Mailing Address - Phone:918-535-2225
Mailing Address - Fax:
Practice Address - Street 1:399351 W 2750 RD
Practice Address - Street 2:
Practice Address - City:RAMONA
Practice Address - State:OK
Practice Address - Zip Code:74061-3349
Practice Address - Country:US
Practice Address - Phone:918-535-2225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-20
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK136235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist