Healthcare Provider Details

I. General information

NPI: 1518295500
Provider Name (Legal Business Name): SHANNON ANN STALOCH LM, CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2009
Last Update Date: 08/15/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2479 LE CONTE AVE APT 3
BERKELEY CA
94709-1236
US

IV. Provider business mailing address

2479 LE CONTE AVE APT 3
BERKELEY CA
94709-1236
US

V. Phone/Fax

Practice location:
  • Phone: 408-464-1441
  • Fax: 510-991-1562
Mailing address:
  • Phone: 408-464-1441
  • Fax: 510-991-1562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberLM249
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: