Provider Demographics
NPI:1841895422
Name:VASCONCELLOS, SHANNON JO
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:JO
Last Name:VASCONCELLOS
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 1:1622 OREGON AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-3379
Mailing Address - Country:US
Mailing Address - Phone:954-253-8580
Mailing Address - Fax:
Practice Address - Street 1:105 MAPLEWOOD DR
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-2147
Practice Address - Country:US
Practice Address - Phone:304-368-8733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV487242Medicaid