Healthcare Provider Details

I. General information

NPI: 1417796293
Provider Name (Legal Business Name): SHANNON PORCH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2024
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 CARSON ST
HOT SPRINGS AR
71901-6852
US

IV. Provider business mailing address

407 CARSON ST
HOT SPRINGS AR
71901-6852
US

V. Phone/Fax

Practice location:
  • Phone: 501-620-5525
  • Fax: 501-321-9828
Mailing address:
  • Phone: 501-620-5525
  • Fax: 501-321-9828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberR044932
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: