Provider Demographics
NPI:1669777918
Name:CAGG, SHANNON SUZANN
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:SUZANN
Last Name:CAGG
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:PO BOX 72
Mailing Address - Street 2:
Mailing Address - City:THOMAS
Mailing Address - State:OK
Mailing Address - Zip Code:73669-0072
Mailing Address - Country:US
Mailing Address - Phone:580-302-2661
Mailing Address - Fax:
Practice Address - Street 1:700 N OKLAHOMA ST
Practice Address - Street 2:
Practice Address - City:THOMAS
Practice Address - State:OK
Practice Address - Zip Code:73669-8137
Practice Address - Country:US
Practice Address - Phone:580-661-2812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator