Provider Demographics
NPI:1912762154
Name:RASBERRY-SHANNON, ANGELA
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:RASBERRY-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 1:2021 4TH AVE NW TRLR 134
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-2525
Mailing Address - Country:US
Mailing Address - Phone:405-695-0390
Mailing Address - Fax:
Practice Address - Street 1:2021 4TH AVE NW TRLR 134
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-2525
Practice Address - Country:US
Practice Address - Phone:405-695-0390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-16
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker