Provider Demographics
NPI:1447808456
Name:VANDERPOOL, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:VANDERPOOL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 DARTMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77840-7042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1907 DARTMOUTH ST
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77840-7042
Practice Address - Country:US
Practice Address - Phone:797-220-0057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX161835164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse