Healthcare Provider Details

I. General information

NPI: 1962351635
Provider Name (Legal Business Name): KATELYN SHANNON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 HAIL KNOB RD
SOMERSET KY
42503-3434
US

IV. Provider business mailing address

75 HAIL KNOB RD
SOMERSET KY
42503-3434
US

V. Phone/Fax

Practice location:
  • Phone: 606-678-9617
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: