Provider Demographics
NPI:1922574920
Name:GILEBARTO, SHANNON RENEE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:RENEE
Last Name:GILEBARTO
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 1:1234 EMPIRE ST STE 2200
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-5711
Mailing Address - Country:US
Mailing Address - Phone:707-731-3757
Mailing Address - Fax:
Practice Address - Street 1:10 4TH AVE
Practice Address - Street 2:
Practice Address - City:ISLETON
Practice Address - State:CA
Practice Address - Zip Code:95641-0673
Practice Address - Country:US
Practice Address - Phone:707-731-3757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2018-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA699004164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA699004OtherBOVNPT
CA$$$$$$$$$OtherSOCIAL SECURITY