Basic Information
| Provider Information | |||||||||
| NPI: | 1215171061 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHANNON | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | GAIL | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2578 | ||||||||
| Address2: | HEALTH RESOURCES OF ARKANSAS | ||||||||
| City: | BATESVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725032578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707938900 | ||||||||
| FaxNumber: | 8707938959 | ||||||||
| Practice Location | |||||||||
| Address1: | #8 MEDICAL PLAZA | ||||||||
| Address2: | HEALTH RESOURCES OF ARKANSAS | ||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704256901 | ||||||||
| FaxNumber: | 8704240903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2009 | ||||||||
| LastUpdateDate: | 04/23/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | LPT-002955 | AR | Y | Nursing Service Providers | Licensed Practical Nurse |
ID Information
| ID | Type | State | Issuer | Description | LTP-002955 | 01 | AR | LPN | OTHER |