=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720979131
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON MICHAEL DNP, APRN, FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2025
-----------------------------------------------------
Last Update Date | 09/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 W 18TH ST STE 140
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73013-3759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-696-7003
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6605 EDGEWATER DR
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73116-1822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-213-6111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 224646
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------