Healthcare Provider Details

I. General information

NPI: 1669788204
Provider Name (Legal Business Name): SHANNON L CHILDERS-PAGE CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON L PAGE CNS

II. Dates (important events)

Enumeration Date: 08/20/2010
Last Update Date: 04/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 N SENATE BLVD # A5231
INDIANAPOLIS IN
46202-1239
US

IV. Provider business mailing address

461 TOWN CENTER ST N
MOORESVILLE IN
46158-2316
US

V. Phone/Fax

Practice location:
  • Phone: 317-962-1429
  • Fax:
Mailing address:
  • Phone: 317-497-6700
  • Fax: 317-497-6711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number71003354A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code364SA2100X
TaxonomyAcute Care Clinical Nurse Specialist
License Number28123065A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: