Provider Demographics
NPI:1952944068
Name:BOON, SHIRLEY WILSON
Entity Type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:WILSON
Last Name:BOON
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 1:43909 30TH ST W
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93536-5843
Mailing Address - Country:US
Mailing Address - Phone:661-600-6206
Mailing Address - Fax:
Practice Address - Street 1:43909 30TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93536-5843
Practice Address - Country:US
Practice Address - Phone:661-600-6206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAU1204834225500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU1204834Medicaid