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Individual
SHANNELLE SUSANNE RICO
Active
Individual
SHANNELLE SUSANNE RICO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01050363A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000378568
BLUE CROSS
IN
05
—
200381310
—
IN
Enumeration date
03/27/2006
Last updated
07/16/2015
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