Provider Demographics
NPI:1831565910
Name:DIAZ, SHANON (MED)
Entity type:Individual
Prefix:
First Name:SHANON
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 RUSSELL ST APT 2A
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-3974
Mailing Address - Country:US
Mailing Address - Phone:774-454-9373
Mailing Address - Fax:
Practice Address - Street 1:50 RUSSELL ST APT 2A
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-3974
Practice Address - Country:US
Practice Address - Phone:774-454-9373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist