Basic Information
| Provider Information | |||||||||
| NPI: | 1255708012 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALLOU | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | |||||||||
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| Credential: | APRN, FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3811 W GORE BLVD STE 6 | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735056328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802506525 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3811 W GORE BLVD STE 6 | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735056328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802506525 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2015 | ||||||||
| LastUpdateDate: | 08/27/2015 | ||||||||
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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 | 363LF0000X | 106662 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.