Provider Demographics
NPI:1063495463
Name:KELLISON, SHAWNEE LYNN (RNBCFNP)
Entity Type:Individual
Prefix:
First Name:SHAWNEE
Middle Name:LYNN
Last Name:KELLISON
Suffix:
Gender:F
Credentials:RNBCFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W JEFFERSON ST
Mailing Address - Street 2:PO BOX 7545
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-1441
Mailing Address - Country:US
Mailing Address - Phone:660-626-2191
Mailing Address - Fax:660-626-2396
Practice Address - Street 1:700 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-1441
Practice Address - Country:US
Practice Address - Phone:660-626-2191
Practice Address - Fax:660-626-2396
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113721163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO501218200OtherMEDICAID GROUP #
MO428713812Medicaid
MODG4290OtherRAILROAD MEDICARE GROUP #
000014853OtherMEDICARE GROUP #
MOP00435145OtherRAILROAD MEDICARE PTAN
MO501218200OtherMEDICAID GROUP #
S29474Medicare UPIN