MEDICARE: SHANNON LEA ROBERTSON

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	164X00000X	Licensed Vocational Nurse	331741	TX

General Provider Information

NPI Number	:	1669961819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON LEA ROBERTSON

Provider Business Mailing Address
First Line	:	4251 GOLDING AVE APT 5207
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76155-2141
Country	:	US
Telephone Number	:	903-328-0774
Fax Number	:

Provider Business Practice Location Address
First Line	:	4251 GOLDING AVE APT 5207
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76155-2141
Country	:	US
Telephone Number	:	903-328-0774
Fax Number	:

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

Provider Enumeration Date	:	05/03/2018
Last Update Date	:	05/03/2018

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