Provider Demographics
NPI:1861126088
Name:CLARK, SHANNA LA RHONDA
Entity type:Individual
Prefix:MS
First Name:SHANNA
Middle Name:LA RHONDA
Last Name:CLARK
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 1:14298 CHANTRY DR
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-4946
Mailing Address - Country:US
Mailing Address - Phone:818-224-9309
Mailing Address - Fax:
Practice Address - Street 1:1001 S HALE AVE SPC 54
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92029-2177
Practice Address - Country:US
Practice Address - Phone:858-729-8295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
B8422966OtherDRIVER LICENSE