Provider Demographics
NPI:1952846537
Name:MARTIN, SHANNON (LVN)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23580 ALESSANDRO BLVD UNIT 9307
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92552-6128
Mailing Address - Country:US
Mailing Address - Phone:951-842-9579
Mailing Address - Fax:
Practice Address - Street 1:22346 HAWTHORN AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-6988
Practice Address - Country:US
Practice Address - Phone:951-842-9579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA266499164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse