Provider Demographics
NPI:1063956084
Name:BRENSON, SHONTA
Entity type:Individual
Prefix:
First Name:SHONTA
Middle Name:
Last Name:BRENSON
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 1:1323 NW HIDDEN RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64015-2719
Mailing Address - Country:US
Mailing Address - Phone:816-812-3092
Mailing Address - Fax:
Practice Address - Street 1:1323 NW HIDDEN RIDGE CIR
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64015-2719
Practice Address - Country:US
Practice Address - Phone:816-812-3092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-09
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO246RP1900X246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy