Healthcare Provider Details

I. General information

NPI: 1477475119
Provider Name (Legal Business Name): ALYSSA GRACE SHANKLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6965 CUMBERLAND GAP PKWY
HARROGATE TN
37752-8245
US

IV. Provider business mailing address

2607 FLYING EBONY DR
LEXINGTON KY
40509-4483
US

V. Phone/Fax

Practice location:
  • Phone: 423-869-3611
  • Fax:
Mailing address:
  • Phone: 606-794-7523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: