Provider Demographics
NPI:1902377484
Name:NELSON, SHAUNTEL RENEE (RAD-T)
Entity Type:Individual
Prefix:
First Name:SHAUNTEL
Middle Name:RENEE
Last Name:NELSON
Suffix:
Gender:F
Credentials:RAD-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-4201
Mailing Address - Country:US
Mailing Address - Phone:442-324-7119
Mailing Address - Fax:
Practice Address - Street 1:1481 N. WINDSOR DR.
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404
Practice Address - Country:US
Practice Address - Phone:909-361-6470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program