Healthcare Provider Details

I. General information

NPI: 1346534385
Provider Name (Legal Business Name): SHANNON ROSS R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 06/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3641 YOUTH TOWN RD
PINSON TN
38366-9804
US

IV. Provider business mailing address

PO BOX 1385
JACKSON TN
38302-1385
US

V. Phone/Fax

Practice location:
  • Phone: 731-988-5251
  • Fax: 731-427-5605
Mailing address:
  • Phone: 731-988-5251
  • Fax: 731-427-5605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN0000090887
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: