Basic Information
| Provider Information | |||||||||
| NPI: | 1275509739 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUSSEY | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3439 | ||||||||
| Address2: | |||||||||
| City: | NORTH MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295820439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434975929 | ||||||||
| FaxNumber: | 8433990123 | ||||||||
| Practice Location | |||||||||
| Address1: | 3361 HIGHWAY 9 E | ||||||||
| Address2: | |||||||||
| City: | LITTLE RIVER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295667826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434975929 | ||||||||
| FaxNumber: | 8667789612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 11/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R 690504 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207N00000X | 846 | SC | N | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 136604 | 05 | SC | MEDICAID |