MEDICARE: MS. SHANNON LESLEE ISOM RNCRD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133NN1002X	Nutrition Education Nutritionist	RN13811	NV
2	163W00000X	Registered Nurse	RN 13811	NV
3	163WD0400X	Diabetes Educator Registered Nurse	RN13811	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	RN13811	OTHER	NV	REGISTERED NURSE
2	100500484	OTHER	NV	GROUP MEDICIAD
3	RDCDE	OTHER	NV	CERTIFIED DIABETES EDUCAT

General Provider Information

NPI Number	:	1184846107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHANNON LESLEE ISOM RNCRD

Provider Business Mailing Address
First Line	:	PO BOX 33166
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89133-3166
Country	:	US
Telephone Number	:	702-641-8500
Fax Number	:	702-641-8502

Provider Business Practice Location Address
First Line	:	6850 N DURANGO DR
Second Line	:	STE 301
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-4595
Country	:	US
Telephone Number	:	702-641-8500
Fax Number	:	702-641-8502

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	02/06/2013

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Directions to “ MS. SHANNON LESLEE ISOM RNCRD” Practice Location

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