Provider Demographics
NPI:1912592056
Name:WATSON, SHANNA RAY
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:RAY
Last Name:WATSON
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 1:29505 CAMINO CRISTAL
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-7567
Mailing Address - Country:US
Mailing Address - Phone:318-455-6149
Mailing Address - Fax:
Practice Address - Street 1:7891 MISSION GROVE PKWY S
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92508-5056
Practice Address - Country:US
Practice Address - Phone:951-776-9223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator