Provider Demographics
NPI:1588102875
Name:SHONE, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SHONE
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 4260
Mailing Address - Street 2:
Mailing Address - City:BLUE GAP
Mailing Address - State:AZ
Mailing Address - Zip Code:86520-4260
Mailing Address - Country:US
Mailing Address - Phone:505-507-9178
Mailing Address - Fax:928-725-3157
Practice Address - Street 1:2.5 MILES SW BLUE GAP STORE
Practice Address - Street 2:
Practice Address - City:BLUE GAP
Practice Address - State:AZ
Practice Address - Zip Code:86520
Practice Address - Country:US
Practice Address - Phone:505-507-9178
Practice Address - Fax:928-725-3157
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ010738Medicaid