Healthcare Provider Details

I. General information

NPI: 1295610632
Provider Name (Legal Business Name): SHENA ANTRONETTE MANNING RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHENA ANTRONETTE SHEAD

II. Dates (important events)

Enumeration Date: 08/06/2025
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6340 E BOISE ST
MESA AZ
85205-8341
US

IV. Provider business mailing address

6040 E MAIN ST STE 149
MESA AZ
85205-8928
US

V. Phone/Fax

Practice location:
  • Phone: 773-513-9131
  • Fax:
Mailing address:
  • Phone: 773-513-9131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN209840
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: