Healthcare Provider Details

I. General information

NPI: 1215171061
Provider Name (Legal Business Name): AMANDA GAIL SHANNON LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2009
Last Update Date: 04/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

#8 MEDICAL PLAZA HEALTH RESOURCES OF ARKANSAS
MOUNTAIN HOME AR
72653
US

IV. Provider business mailing address

PO BOX 2578 HEALTH RESOURCES OF ARKANSAS
BATESVILLE AR
72503-2578
US

V. Phone/Fax

Practice location:
  • Phone: 870-425-6901
  • Fax: 870-424-0903
Mailing address:
  • Phone: 870-793-8900
  • Fax: 870-793-8959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPT-002955
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: