Provider Demographics
NPI:1336792555
Name:NELSON, SHAWNA
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:NELSON
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 1:935 RIVERDALE ST
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-4656
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:935 RIVERDALE ST
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-4656
Practice Address - Country:US
Practice Address - Phone:413-733-8511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0014641183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist