Provider Demographics
NPI:1669961819
Name:ROBERTSON, SHANNON LEA
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEA
Last Name:ROBERTSON
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 1:4251 GOLDING AVE APT 5207
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76155-2141
Mailing Address - Country:US
Mailing Address - Phone:903-328-0774
Mailing Address - Fax:
Practice Address - Street 1:4251 GOLDING AVE APT 5207
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76155-2141
Practice Address - Country:US
Practice Address - Phone:903-328-0774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX331741164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse