Provider Demographics
NPI:1265938807
Name:HAVENS, SHANNON MARIE
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MARIE
Last Name:HAVENS
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 1:8617 CASLER CIR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-5242
Mailing Address - Country:US
Mailing Address - Phone:254-217-1604
Mailing Address - Fax:
Practice Address - Street 1:13915 BURNET RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78728-6517
Practice Address - Country:US
Practice Address - Phone:903-532-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX172506164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse