Healthcare Provider Details

I. General information

NPI: 1184846107
Provider Name (Legal Business Name): SHANNON LESLEE ISOM RNCRD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. SHANNON LESLEE ENCE

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 02/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6850 N DURANGO DR STE 301
LAS VEGAS NV
89149-4595
US

IV. Provider business mailing address

PO BOX 33166
LAS VEGAS NV
89133-3166
US

V. Phone/Fax

Practice location:
  • Phone: 702-641-8500
  • Fax: 702-641-8502
Mailing address:
  • Phone: 702-641-8500
  • Fax: 702-641-8502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberRN13811
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN 13811
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberRN13811
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: