Healthcare Provider Details

I. General information

NPI: 1194363887
Provider Name (Legal Business Name): SHANNON BRACEY APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON BROWN

II. Dates (important events)

Enumeration Date: 12/13/2019
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE ST
LEXINGTON KY
40536
US

IV. Provider business mailing address

3333 BURNET AVE # MLC1013
CINCINNATI OH
45229-3026
US

V. Phone/Fax

Practice location:
  • Phone: 859-562-1085
  • Fax:
Mailing address:
  • Phone: 859-227-5108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3015437
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.026339
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number3015437
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: