Basic Information
| Provider Information | |||||||||
| NPI: | 1538343678 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EMMERT | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376014877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239292584 | ||||||||
| FaxNumber: | 4237222060 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376014877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239292584 | ||||||||
| FaxNumber: | 4237222060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2007 | ||||||||
| LastUpdateDate: | 04/10/2019 | ||||||||
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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 | F0207068 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1521248 | 05 | TN | MEDICAID |