Provider Demographics
NPI:1033179817
Name:BENTLEY, SHANNON K (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:K
Last Name:BENTLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:413 S LOOP RD
Mailing Address - Street 2:ST ELIZABETH FAMILY PRACTICE CENTER
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-5446
Mailing Address - Country:US
Mailing Address - Phone:859-301-3800
Mailing Address - Fax:859-301-3987
Practice Address - Street 1:413 SOUTH LOOP ROAD
Practice Address - Street 2:ST ELIZABETH FAMILY PRACTICE CENTER
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-5446
Practice Address - Country:US
Practice Address - Phone:859-301-3800
Practice Address - Fax:859-301-3987
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35.075269207Q00000X
WV22184207Q00000X
KY49699207VX0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100457110Medicaid
KYK228150OtherKY MEDICARE
KYK228150OtherKY MEDICARE
H18042Medicare UPIN