Provider Demographics
NPI:1740068758
Name:ROUSSOS, SHANNON (IBCLC)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:ROUSSOS
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2479 MABRY DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95835-1513
Mailing Address - Country:US
Mailing Address - Phone:443-257-7846
Mailing Address - Fax:
Practice Address - Street 1:2479 MABRY DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95835-1513
Practice Address - Country:US
Practice Address - Phone:443-257-7846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA675696163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant