1760688469 NPI number — MRS. SHANNON M NILEST M.ED., LPP

Table of content: MRS. SHANNON M NILEST M.ED., LPP (NPI 1760688469)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760688469 NPI number — MRS. SHANNON M NILEST M.ED., LPP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NILEST
Provider First Name:
SHANNON
Provider Middle Name:
M
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.ED., LPP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MAHONEY
Provider Other First Name:
SHANNON
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.ED. LPP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760688469
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 W MUHAMMAD ALI BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40202-1423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-589-8600
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4710 CHAMPIONS TRACE LN
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40218-3495
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-454-6353
Provider Business Practice Location Address Fax Number:
502-459-9209
Provider Enumeration Date:
06/21/2007

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: 103T00000X , with the licence number:  114308 , 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)





Copyright © 2007-2025 www.npivalidator.com