Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician |
NPI | 1114340718 |
---|---|
Provider Name | Shannon Intrepidi |
First Address | Minocqua, WI 54548-0182 |
Second Address | Minocqua, WI 54548 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/02/2014 |
Last Update Date | 03/02/2014 |