Provider Demographics
NPI:1982098919
Name:LANCE, SHANNON (ATC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:LANCE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1341 E 146TH PL S
Mailing Address - Street 2:
Mailing Address - City:GLENPOOL
Mailing Address - State:OK
Mailing Address - Zip Code:74033-3714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3900 N MINGO RD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74116-5000
Practice Address - Country:US
Practice Address - Phone:918-292-3397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7752255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer