Provider Demographics
NPI:1043656762
Name:ROUSSELO, SHANNON NICOLE (RRT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:ROUSSELO
Suffix:
Gender:F
Credentials:RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1068 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-5427
Mailing Address - Country:US
Mailing Address - Phone:909-333-2180
Mailing Address - Fax:
Practice Address - Street 1:11201 BENTON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92357-1000
Practice Address - Country:US
Practice Address - Phone:909-825-7084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225B00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPulmonary Function Technologist