Healthcare Provider Details

I. General information

NPI: 1801090444
Provider Name (Legal Business Name): SHAUNDELLE ANN OLUSANYA DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 04/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 S BISHOP AVE
ROLLA MO
65401-4411
US

IV. Provider business mailing address

1060 S BISHOP AVE
ROLLA MO
65401-4411
US

V. Phone/Fax

Practice location:
  • Phone: 573-426-5900
  • Fax: 573-426-4466
Mailing address:
  • Phone: 573-426-5900
  • Fax: 573-426-4466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2003014072
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: