Healthcare Provider Details

I. General information

NPI: 1588588040
Provider Name (Legal Business Name): SHANTELLE BREANNE HOUSTON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 MEYERS BAKER RD STE 200
LONDON KY
40741-3040
US

IV. Provider business mailing address

PO BOX 748817
ATLANTA GA
30374-8817
US

V. Phone/Fax

Practice location:
  • Phone: 606-878-3240
  • Fax: 606-878-4308
Mailing address:
  • Phone: 813-286-0033
  • Fax: 813-282-1806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4059599
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: