Provider Demographics
NPI:1801671177
Name:SHANNON, IMANI L
Entity type:Individual
Prefix:
First Name:IMANI
Middle Name:L
Last Name:SHANNON
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 1:1919 GRAND CANAL BLVD
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-8135
Mailing Address - Country:US
Mailing Address - Phone:415-423-4476
Mailing Address - Fax:
Practice Address - Street 1:1919 GRAND CANAL BLVD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-8135
Practice Address - Country:US
Practice Address - Phone:415-423-4476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF7077821172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver