Healthcare Provider Details

I. General information

NPI: 1619148103
Provider Name (Legal Business Name): SHANNA DORLON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2008
Last Update Date: 03/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1077 BRANSON HILLS PKWY SUITE N
BRANSON MO
65616-9940
US

IV. Provider business mailing address

1077 BRANSON HILLS PKWY SUITE N
BRANSON MO
65616-9940
US

V. Phone/Fax

Practice location:
  • Phone: 417-336-1801
  • Fax: 417-336-1803
Mailing address:
  • Phone: 417-336-1801
  • Fax: 417-336-1803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number0800011732
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: