Healthcare Provider Details

I. General information

NPI: 1437078102
Provider Name (Legal Business Name): SHANNON NICOLE MABRY SMITH APRN-CNP/PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 SPLENDOR LN
OLIVE HILL KY
41164-6098
US

IV. Provider business mailing address

39 SPLENDOR LN
OLIVE HILL KY
41164-6098
US

V. Phone/Fax

Practice location:
  • Phone: 606-367-8525
  • Fax:
Mailing address:
  • Phone: 606-367-8525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4058367
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: