Provider Demographics
NPI:1255736807
Name:WEBSTER, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WEBSTER
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 1:911 FARRAGUT
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708
Mailing Address - Country:US
Mailing Address - Phone:989-252-1106
Mailing Address - Fax:
Practice Address - Street 1:911 N FARRAGUT ST
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-6039
Practice Address - Country:US
Practice Address - Phone:989-252-1106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-24
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703106332164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse