Provider Demographics
NPI:1831255074
Name:LUSTILA, SHANNON CATHLEEN
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:CATHLEEN
Last Name:LUSTILA
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 1:201 HEMATITE ST
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-3129
Mailing Address - Country:US
Mailing Address - Phone:218-263-4840
Mailing Address - Fax:
Practice Address - Street 1:201 HEMATITE ST
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-3129
Practice Address - Country:US
Practice Address - Phone:218-263-4840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN222281-1-AFC177F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes177F00000XOther Service ProvidersLodging