Healthcare Provider Details

I. General information

NPI: 1093325532
Provider Name (Legal Business Name): SHANNON YEE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2020
Last Update Date: 08/07/2020
Certification Date: 08/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4310 SANDY RIVER DR UNIT 73
LAS VEGAS NV
89103-6108
US

IV. Provider business mailing address

4310 SANDY RIVER DR UNIT 73
LAS VEGAS NV
89103-6108
US

V. Phone/Fax

Practice location:
  • Phone: 773-501-7492
  • Fax:
Mailing address:
  • Phone: 773-501-7492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7169
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: