Healthcare Provider Details

I. General information

NPI: 1891626487
Provider Name (Legal Business Name): SHANNON NOWELLE MYERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4681 OSAGE BEACH PKWY
OSAGE BEACH MO
65065-2069
US

IV. Provider business mailing address

PO BOX 1265
LAKE OZARK MO
65049-1265
US

V. Phone/Fax

Practice location:
  • Phone: 573-302-4909
  • Fax:
Mailing address:
  • Phone: 573-280-0005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224900000X
TaxonomyMastectomy Fitter
License NumberC73524
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: