=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821704628
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON D FYFFE APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2023
-----------------------------------------------------
Last Update Date | 01/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 147 N HIGHLAND AVE
-----------------------------------------------------
City | PRESTONSBURG
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41653-7748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-262-2882
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1241 HIGHWAY 469
-----------------------------------------------------
City | MARTHA
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41159-9023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-471-4342
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 3018611
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------