Basic Information
| Provider Information | |||||||||
| NPI: | 1538409958 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIRLEY | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHIRLEY | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 280 FORT SANDERS WEST BLVD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379223351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655390270 | ||||||||
| FaxNumber: | 8655396998 | ||||||||
| Practice Location | |||||||||
| Address1: | 280 FORT SANDERS WEST BLVD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379223351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655390270 | ||||||||
| FaxNumber: | 8655396998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2013 | ||||||||
| LastUpdateDate: | 02/21/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2297 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.