Provider Demographics
NPI:1922367507
Name:SHANNON, LISA R (LMT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:SHANNON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-9285
Mailing Address - Country:US
Mailing Address - Phone:302-468-9416
Mailing Address - Fax:
Practice Address - Street 1:5 BRIDGE CT
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-9285
Practice Address - Country:US
Practice Address - Phone:302-468-9416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEMT0003080174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist