Provider Demographics
NPI:1285909770
Name:IRVING, SHANNON LIAT
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LIAT
Last Name:IRVING
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:PO BOX 281
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:99559-0281
Mailing Address - Country:US
Mailing Address - Phone:907-545-5716
Mailing Address - Fax:
Practice Address - Street 1:460 RIDGECREST AVE
Practice Address - Street 2:FAMILY INFANT TODDLER PROGRAM-SUITE 214
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559-0281
Practice Address - Country:US
Practice Address - Phone:907-543-1778
Practice Address - Fax:907-543-1276
Is Sole Proprietor?:No
Enumeration Date:2012-03-15
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1002573Medicaid