Healthcare Provider Details

I. General information

NPI: 1083924104
Provider Name (Legal Business Name): SHANNON VIRGINIA COOK RN, FNP-BC, WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2010
Last Update Date: 03/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 N MERIDIAN ST
INDIANAPOLIS IN
46202-2306
US

IV. Provider business mailing address

1545 N MERIDIAN ST
INDIANAPOLIS IN
46202-2306
US

V. Phone/Fax

Practice location:
  • Phone: 317-850-7158
  • Fax:
Mailing address:
  • Phone: 317-850-7158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number28169430A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN1031235
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024171259
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71006911A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: