Provider Demographics
NPI:1437769239
Name:LASANE, SHANNEN J
Entity type:Individual
Prefix:
First Name:SHANNEN
Middle Name:J
Last Name:LASANE
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 1:4006 GOLF VILLAGE LOOP APT 2
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-4056
Mailing Address - Country:US
Mailing Address - Phone:863-604-0157
Mailing Address - Fax:
Practice Address - Street 1:4006 GOLF VILLAGE LOOP APT 2
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-4056
Practice Address - Country:US
Practice Address - Phone:863-604-0157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL841897717Medicaid