1144350422 NPI number — MRS. SHANNON MARIE MIRACLE CNA

Table of content: MRS. SHANNON MARIE MIRACLE CNA (NPI 1144350422)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144350422 NPI number — MRS. SHANNON MARIE MIRACLE CNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIRACLE
Provider First Name:
SHANNON
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144350422
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1291 BARKLEY HILLS CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLARKSVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37040-8103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-648-1405
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
511 8TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARKSVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37040-3093
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-920-7200
Provider Business Practice Location Address Fax Number:
931-920-7206
Provider Enumeration Date:
03/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 376K00000X , with the licence number:  00119156 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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