Individual
SHANNON MONIQUE MEDINA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
13 OLD SCHOOL RD, PENASCO, NM 87553
(575) 587-2502
Mailing address
PO BOX 520, PENASCO, NM 87553-0520
(575) 587-2502
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
Primary
X-11248
NM
1041S0200X
School Social Worker
376369
NM
Other
Enumeration date
09/18/2019
Last updated
09/18/2019
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