Provider Demographics
NPI:1164601886
Name:CHARLES, SHANNON (BA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:CHARLES
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:104 S FRONT AVE
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-1614
Mailing Address - Country:US
Mailing Address - Phone:606-886-8572
Mailing Address - Fax:606-886-4433
Practice Address - Street 1:40 GREENHOUSE LN
Practice Address - Street 2:RT 321 AUXIER ROAD
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-9180
Practice Address - Country:US
Practice Address - Phone:606-886-6815
Practice Address - Fax:606-886-9878
Is Sole Proprietor?:No
Enumeration Date:2007-10-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist