Provider Demographics
NPI:1053034751
Name:SIEBERT, SHANIA
Entity type:Individual
Prefix:
First Name:SHANIA
Middle Name:
Last Name:SIEBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANIA
Other - Middle Name:
Other - Last Name:COLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:478 BRECKENRIDGE TRCE
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37663-2988
Mailing Address - Country:US
Mailing Address - Phone:816-341-4236
Mailing Address - Fax:
Practice Address - Street 1:102 E RAVINE RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3814
Practice Address - Country:US
Practice Address - Phone:423-245-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program