=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205378247
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON BROOKE LITTLE RN; BSN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2016
-----------------------------------------------------
Last Update Date | 11/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 524 SIGNAL HILL DRIVE EXT
-----------------------------------------------------
City | STATESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28625-4391
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-871-1045
-----------------------------------------------------
Fax | 704-873-6647
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 284 EXECUTIVE PARK DR SUITE 100
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28025-1894
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-939-1100
-----------------------------------------------------
Fax | 704-939-1173
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Registered Nurse
-----------------------------------------------------
License Number | 177415
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------