=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184976151
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON R YOUNG APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2012
-----------------------------------------------------
Last Update Date | 07/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 404 STEVE DRIVE
-----------------------------------------------------
City | RUSSELL SPRINGS
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42642-4622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-866-3161
-----------------------------------------------------
Fax | 270-866-3163
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1080
-----------------------------------------------------
City | BURKESVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42717-1080
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-864-1472
-----------------------------------------------------
Fax | 270-864-1693
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 3007710
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------