Provider Demographics
NPI:1083673800
Name:SMITH, SHANNON LEIGH (ARNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEIGH
Last Name:SMITH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 950166
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0166
Mailing Address - Country:US
Mailing Address - Phone:502-253-1035
Mailing Address - Fax:502-253-1037
Practice Address - Street 1:12010 SHELBYVILLE RD
Practice Address - Street 2:STE 500
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-1054
Practice Address - Country:US
Practice Address - Phone:502-238-2800
Practice Address - Fax:502-238-2805
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4407P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78015963Medicaid
KY0789703Medicare PIN
KYQ41742Medicare UPIN
KY0953531Medicare PIN