Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | RDH2965 | ME |
NPI | 1013475060 |
---|---|
Provider Name | Shannon Rachel Faxon |
First Address | Windham, ME 04062-5636 |
Second Address | Windham, ME 04062-5636 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/03/2019 |
Last Update Date | 08/03/2019 |