Healthcare Provider Details

I. General information

NPI: 1659159564
Provider Name (Legal Business Name): SHANNON TAYLOR LAVENDER COOK MSN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2023
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 KANAWHA TER
SAINT ALBANS WV
25177-2750
US

IV. Provider business mailing address

97 GREAT TEAYS BLVD STE 6
SCOTT DEPOT WV
25560-9816
US

V. Phone/Fax

Practice location:
  • Phone: 304-201-1130
  • Fax: 304-201-1134
Mailing address:
  • Phone: 304-757-6999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number104481
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number104481
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: