MEDICARE: SHANNON BLACKBURN FNP-C

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	363LF0000X	Family Nurse Practitioner	1094171	TX

General Provider Information

NPI Number	:	1518689611
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON BLACKBURN FNP-C

Provider Business Mailing Address
First Line	:	21309 FOSTER RD STE 100
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77388-4209
Country	:	US
Telephone Number	:	281-587-1700
Fax Number	:	281-907-6003

Provider Business Practice Location Address
First Line	:	21309 FOSTER RD
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77388-4209
Country	:	US
Telephone Number	:	281-587-1700
Fax Number	:	281-907-6003

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

Provider Enumeration Date	:	09/15/2022
Last Update Date	:	09/15/2022

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