Healthcare Provider Details

I. General information

NPI: 1831830629
Provider Name (Legal Business Name): SHANNON KISS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 E CHAPMAN AVE STE 400
ORANGE CA
92869-3204
US

IV. Provider business mailing address

2501 E CHAPMAN AVE STE 400
ORANGE CA
92869-3204
US

V. Phone/Fax

Practice location:
  • Phone: 714-282-1892
  • Fax:
Mailing address:
  • Phone: 714-282-1892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number20A25222
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: