Healthcare Provider Details

I. General information

NPI: 1770745879
Provider Name (Legal Business Name): SHANNON FRANKLIN SHELLEY O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 07/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 N MAIN ST
SPARTA TN
38583-2063
US

IV. Provider business mailing address

25 N MAIN ST
SPARTA TN
38583-2063
US

V. Phone/Fax

Practice location:
  • Phone: 931-836-2235
  • Fax: 931-836-3036
Mailing address:
  • Phone: 931-836-2235
  • Fax: 931-836-3036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2809
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: