Healthcare Provider Details

I. General information

NPI: 1578389961
Provider Name (Legal Business Name): SHANNON DENNIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38259 HIGHWAY 621 TRLR 15
GONZALES LA
70737-6288
US

IV. Provider business mailing address

38259 HIGHWAY 621 TRLR 15
GONZALES LA
70737-6288
US

V. Phone/Fax

Practice location:
  • Phone: 225-461-9607
  • Fax:
Mailing address:
  • Phone: 225-461-9607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number278948
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: