Healthcare Provider Details

I. General information

NPI: 1184214157
Provider Name (Legal Business Name): SHANNON KATHLEEN CHAPPELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2021
Last Update Date: 01/22/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4864 JACKSON ST
MONROE LA
71202-6400
US

IV. Provider business mailing address

191 PR 1127
FAIRFIELD TX
75840
US

V. Phone/Fax

Practice location:
  • Phone: 318-330-7000
  • Fax:
Mailing address:
  • Phone: 903-390-9392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number324552
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA14107
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: