1619033404 NPI number — MRS. SHANNON RENAE WRIGHT FNP

Table of content: MRS. SHANNON RENAE WRIGHT FNP (NPI 1619033404)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619033404 NPI number — MRS. SHANNON RENAE WRIGHT FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WRIGHT
Provider First Name:
SHANNON
Provider Middle Name:
RENAE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
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:
1619033404
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1027
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JEFFERSON CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65102-1027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-761-7246
Provider Business Mailing Address Fax Number:
573-761-6947

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 HIGHWAY 28 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65013-3405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-859-3775
Provider Business Practice Location Address Fax Number:
573-859-3997
Provider Enumeration Date:
12/28/2006

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: 363LF0000X , with the licence number:  155084 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1619033404 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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