Provider Demographics
NPI:1255052031
Name:CLARK, SHANNON L (RN CCM)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-2510
Mailing Address - Country:US
Mailing Address - Phone:480-929-9909
Mailing Address - Fax:480-804-0384
Practice Address - Street 1:1115 W 5TH ST
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-2510
Practice Address - Country:US
Practice Address - Phone:480-929-9909
Practice Address - Fax:480-804-0384
Is Sole Proprietor?:No
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ242334163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool