Healthcare Provider Details

I. General information

NPI: 1528789419
Provider Name (Legal Business Name): SHANNON BONDOC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2022
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8765 BRANCH AVE STE 29
CLINTON MD
20735-2630
US

IV. Provider business mailing address

4617 STRAUSS AVE
INDIAN HEAD MD
20640-1809
US

V. Phone/Fax

Practice location:
  • Phone: 240-303-3838
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374700000X
TaxonomyTechnician
License Number452330
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License NumberCSES5200390
License Number StateDC
# 4
Primary TaxonomyN
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberCSES5200390
License Number StateDC
# 6
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number452330
License Number StateMD
# 7
Primary TaxonomyN
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License Number452330
License Number StateMD
# 8
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateDC
# 9
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number452330
License Number StateMD
# 10
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 11
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateNULL
# 12
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: