Provider Demographics
NPI:1083924104
Name:COOK, SHANNON VIRGINIA (RN, FNP-BC, WHNP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:VIRGINIA
Last Name:COOK
Suffix:
Gender:F
Credentials:RN, FNP-BC, WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1545 N MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-2306
Mailing Address - Country:US
Mailing Address - Phone:317-850-7158
Mailing Address - Fax:
Practice Address - Street 1:1545 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2306
Practice Address - Country:US
Practice Address - Phone:317-850-7158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-08
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28169430A163WE0003X
DCRN1031235363LF0000X
VA0024171259363LF0000X
IN71006911A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency