1235525809 NPI number — MRS. SHANNON RENEE SHIRLEY MSN, RN, NP-C

Table of content: MRS. SHANNON RENEE SHIRLEY MSN, RN, NP-C (NPI 1235525809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235525809 NPI number — MRS. SHANNON RENEE SHIRLEY MSN, RN, NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHIRLEY
Provider First Name:
SHANNON
Provider Middle Name:
RENEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSN, RN, NP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STEENBERGEN (MAIDEN NAME)
Provider Other First Name:
SHANNON
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1235525809
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1495 S DIXIE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HORSE CAVE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42749-1457
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-786-2372
Provider Business Mailing Address Fax Number:
270-786-2472

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1501 S DIXIE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HORSE CAVE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42749-1480
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-786-2191
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/10/2015

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:  3009340 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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