Healthcare Provider Details

I. General information

NPI: 1578302287
Provider Name (Legal Business Name): SHANNA NICHOLE BLACKWELL FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2024
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 UNION AVE STE 400
MEMPHIS TN
38104-6656
US

IV. Provider business mailing address

1211 UNION AVE STE 330
MEMPHIS TN
38104-6655
US

V. Phone/Fax

Practice location:
  • Phone: 901-478-0650
  • Fax: 901-726-4237
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number36123
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: