Provider Demographics
NPI:1982346458
Name:WILSON, SHANNON MCKAY (NA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MCKAY
Last Name:WILSON
Suffix:
Gender:F
Credentials:NA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 484
Mailing Address - Street 2:
Mailing Address - City:JARALES
Mailing Address - State:NM
Mailing Address - Zip Code:87023-0484
Mailing Address - Country:US
Mailing Address - Phone:505-450-5010
Mailing Address - Fax:
Practice Address - Street 1:3526 WYOMING BLVD NE APT 21-306
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-9414
Practice Address - Country:US
Practice Address - Phone:505-450-5010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician