Basic Information
| Provider Information | |||||||||
| NPI: | 1558463885 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOOLEY | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | MALENA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | N. P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 W LONGEST ST | ||||||||
| Address2: | PO BOX 270 | ||||||||
| City: | PAOLI | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474548821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127237993 | ||||||||
| FaxNumber: | 8127237991 | ||||||||
| Practice Location | |||||||||
| Address1: | 420 W LONGEST ST | ||||||||
| Address2: | |||||||||
| City: | PAOLI | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474548821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127233944 | ||||||||
| FaxNumber: | 8127235292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2006 | ||||||||
| LastUpdateDate: | 12/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71001609A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 200452120A | 05 | IN | MEDICAID |