Provider Demographics
NPI:1427479815
Name:TEDFORD, SHANNON RENEE (IDMT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:RENEE
Last Name:TEDFORD
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 CROSS POINT DR
Mailing Address - Street 2:
Mailing Address - City:OWINGS
Mailing Address - State:MD
Mailing Address - Zip Code:20736-3322
Mailing Address - Country:US
Mailing Address - Phone:731-267-8201
Mailing Address - Fax:
Practice Address - Street 1:156 CROSS POINT DR
Practice Address - Street 2:
Practice Address - City:OWINGS
Practice Address - State:MD
Practice Address - Zip Code:20736-3322
Practice Address - Country:US
Practice Address - Phone:731-267-8201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-02
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians