Healthcare Provider Details

I. General information

NPI: 1447279047
Provider Name (Legal Business Name): SHANNON A. ROBERTS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3084 LAKECREST CIR
LEXINGTON KY
40513-1706
US

IV. Provider business mailing address

PO BOX 910670
LEXINGTON KY
40591-0670
US

V. Phone/Fax

Practice location:
  • Phone: 859-219-6440
  • Fax: 859-219-6449
Mailing address:
  • Phone: 859-971-4685
  • Fax: 859-971-4602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number02918
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: