Healthcare Provider Details

I. General information

NPI: 1295781045
Provider Name (Legal Business Name): SHANNA B PETERSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNA BARTLETT RN

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 10/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 N MAIN AVE SUITE 3
ERWIN TN
37650-9102
US

IV. Provider business mailing address

PO BOX 716
ERWIN TN
37650-0716
US

V. Phone/Fax

Practice location:
  • Phone: 423-743-3440
  • Fax:
Mailing address:
  • Phone: 423-743-3440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPN11999
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: