Provider Demographics
NPI:1083126106
Name:KELLER, SHANNON ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:KELLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:ELIZABETH
Other - Last Name:MCGEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 30459
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-0008
Mailing Address - Country:US
Mailing Address - Phone:931-245-1150
Mailing Address - Fax:931-245-0605
Practice Address - Street 1:1000 HIGHWAY 76
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-8405
Practice Address - Country:US
Practice Address - Phone:931-245-1150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-30
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3427363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant