Healthcare Provider Details

I. General information

NPI: 1316566607
Provider Name (Legal Business Name): SHANNON BUSBY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2020
Last Update Date: 04/16/2020
Certification Date: 04/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 WINTERBROOK DR
CONWAY AR
72034-3564
US

IV. Provider business mailing address

PO BOX 9178
RUSSELLVILLE AR
72811-9178
US

V. Phone/Fax

Practice location:
  • Phone: 479-498-6747
  • Fax: 479-968-1673
Mailing address:
  • Phone: 855-498-6767
  • Fax: 479-968-1673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number124199
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: