Provider Demographics
NPI:1972179059
Name:BUSHELL, SHANNON BARBARA
Entity Type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:BARBARA
Last Name:BUSHELL
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 1:2270 HOTEL CIR N
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-2810
Mailing Address - Country:US
Mailing Address - Phone:619-322-5830
Mailing Address - Fax:
Practice Address - Street 1:2270 HOTEL CIR N
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-2810
Practice Address - Country:US
Practice Address - Phone:619-322-5830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-31
Last Update Date:2021-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator