Healthcare Provider Details

I. General information

NPI: 1497986301
Provider Name (Legal Business Name): SHANNON NOEL LUKEZ ARNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2009
Last Update Date: 03/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2195 CHEAT RD SUITE 2
MORGANTOWN WV
26508-0022
US

IV. Provider business mailing address

2195 CHEAT RD SUITE 2
MORGANTOWN WV
26508-0022
US

V. Phone/Fax

Practice location:
  • Phone: 304-594-0456
  • Fax: 304-594-3249
Mailing address:
  • Phone: 304-594-0456
  • Fax: 304-594-3249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCOA10804NP
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN85183-ANP-BC
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: