Basic Information
Provider Information | |||||||||
NPI: | 1811977499 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HANNER | ||||||||
FirstName: | SHELIA | ||||||||
MiddleName: | G | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSN, FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6049 SHALLOWFORD ROAD | ||||||||
Address2: |   | ||||||||
City: | CHATTANOOGA | ||||||||
State: | TN | ||||||||
PostalCode: | 374211688 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4232666751 | ||||||||
FaxNumber: | 4237634650 | ||||||||
Practice Location | |||||||||
Address1: | 601 CUMBERLAND ST | ||||||||
Address2: |   | ||||||||
City: | CHATTANOOGA | ||||||||
State: | TN | ||||||||
PostalCode: | 374041922 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4232666751 | ||||||||
FaxNumber: | 4237634650 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/19/2006 | ||||||||
LastUpdateDate: | 12/02/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APN6546 | TN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163WP0809X | RN0000087880 | TN | Y |   | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult |
ID Information
ID | Type | State | Issuer | Description | 3905650 | 05 | TN |   | MEDICAID | 500028964 | 01 | TN | RAILROAD MEDICARE | OTHER |