Basic Information
| Provider Information | |||||||||
| NPI: | 1669665964 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | LARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN-ACNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HUMPHREY | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | LARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN, ACNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5002 COWHORN CREEK RD | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755039766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036143000 | ||||||||
| FaxNumber: | 9036143525 | ||||||||
| Practice Location | |||||||||
| Address1: | 5002 COWHORN CREEK RD | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755039766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036143000 | ||||||||
| FaxNumber: | 9036143525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2007 | ||||||||
| LastUpdateDate: | 08/03/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 653277 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2100X | AP115188 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | AP115188 | 01 | TX | APRN | OTHER | 653277 | 01 | TX | RN | OTHER |