Provider Demographics
NPI:1801338835
Name:PANNELL, SHAVONDA (DC)
Entity type:Individual
Prefix:
First Name:SHAVONDA
Middle Name:
Last Name:PANNELL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6117 S MINGO RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-6315
Mailing Address - Country:US
Mailing Address - Phone:918-615-3433
Mailing Address - Fax:918-369-9175
Practice Address - Street 1:1717 N PEORIA AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74106-4400
Practice Address - Country:US
Practice Address - Phone:918-508-2950
Practice Address - Fax:918-508-2952
Is Sole Proprietor?:No
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4125111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor