Healthcare Provider Details

I. General information

NPI: 1487962130
Provider Name (Legal Business Name): SHANNON PATTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2010
Last Update Date: 09/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9993 FOX HALL CT
SAINT ANN MO
63074-2003
US

IV. Provider business mailing address

9993 FOX HALL CT
SAINT ANN MO
63074-2003
US

V. Phone/Fax

Practice location:
  • Phone: 314-427-7825
  • Fax: 314-427-7825
Mailing address:
  • Phone: 314-427-7825
  • Fax: 314-427-7825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2006033512
License Number StateMO

VIII. Authorized Official

Name: SHANNON RENEE PATTON
Title or Position: COTA
Credential:
Phone: 314-427-7825