Provider Demographics
NPI:1184932402
Name:WILSON, SHANNA RAE
Entity type:Individual
Prefix:MISS
First Name:SHANNA
Middle Name:RAE
Last Name:WILSON
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 1:480 GALLETTI WAY #8C
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89431-5564
Mailing Address - Country:US
Mailing Address - Phone:775-324-1490
Mailing Address - Fax:775-324-1541
Practice Address - Street 1:480 GALLETTI WAY # 8C
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89431-5564
Practice Address - Country:US
Practice Address - Phone:775-324-1490
Practice Address - Fax:775-324-1541
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-21
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner