Provider Demographics
NPI:1336555051
Name:WALDON, SHANNON (CSA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WALDON
Suffix:
Gender:F
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4787 ALBEN BARKLEY DR
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-6789
Mailing Address - Country:US
Mailing Address - Phone:270-442-9461
Mailing Address - Fax:270-441-0079
Practice Address - Street 1:510 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-6334
Practice Address - Country:US
Practice Address - Phone:618-997-6800
Practice Address - Fax:618-997-1187
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-02
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4393246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist