Healthcare Provider Details

I. General information

NPI: 1497647135
Provider Name (Legal Business Name): SHANNON MICHELLE NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON MICHELLE MAXIAN

II. Dates (important events)

Enumeration Date: 07/17/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 16TH ST STE 500
WHEELING WV
26003-3610
US

IV. Provider business mailing address

58 16TH ST STE 500
WHEELING WV
26003-3610
US

V. Phone/Fax

Practice location:
  • Phone: 304-242-7751
  • Fax: 304-242-7254
Mailing address:
  • Phone: 304-242-7751
  • Fax: 304-242-7254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.124346
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: