Healthcare Provider Details

I. General information

NPI: 1457021503
Provider Name (Legal Business Name): SHANNON FISH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2021
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 S STATE ROAD 135 STE 310
GREENWOOD IN
46143-5527
US

IV. Provider business mailing address

770 PINE LAKE DR
GREENWOOD IN
46143-7512
US

V. Phone/Fax

Practice location:
  • Phone: 317-497-2400
  • Fax: 317-497-2516
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71011596A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: