Provider Demographics
NPI:1528443520
Name:BANGEMAN, SHONNA
Entity type:Individual
Prefix:
First Name:SHONNA
Middle Name:
Last Name:BANGEMAN
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 1:1112 S VIVIAN ST
Mailing Address - Street 2:
Mailing Address - City:CRANE
Mailing Address - State:TX
Mailing Address - Zip Code:79731-3719
Mailing Address - Country:US
Mailing Address - Phone:580-301-4649
Mailing Address - Fax:
Practice Address - Street 1:1112 S VIVIAN ST
Practice Address - Street 2:
Practice Address - City:CRANE
Practice Address - State:TX
Practice Address - Zip Code:79731-3719
Practice Address - Country:US
Practice Address - Phone:580-301-4649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX47-4555495OtherPRIVATE PAY