MEDICARE: MRS. SHANNON TAYLOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1346690914
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHANNON TAYLOR

Provider Business Mailing Address
First Line	:	1778 N GREGG AVE APT 1
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703-2471
Country	:	US
Telephone Number	:	479-263-8230
Fax Number	:

Provider Business Practice Location Address
First Line	:	1778 N GREGG AVE APT 1
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703-2471
Country	:	US
Telephone Number	:	479-263-8230
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2016
Last Update Date	:	06/15/2016

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