Healthcare Provider Details

I. General information

NPI: 1184221541
Provider Name (Legal Business Name): SHANNON LEE WILLIAMS DNP, APRN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2020
Last Update Date: 05/31/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5807 HARRODS GLEN DR
PROSPECT KY
40059-7650
US

IV. Provider business mailing address

3900 JEFFERSON PARK PL
LOUISVILLE KY
40299-4592
US

V. Phone/Fax

Practice location:
  • Phone: 502-410-0410
  • Fax:
Mailing address:
  • Phone: 502-797-4004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number3015279
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: