Provider Demographics
NPI:1225381767
Name:DIXON, SHANDA SOUTHARD
Entity Type:Individual
Prefix:
First Name:SHANDA
Middle Name:SOUTHARD
Last Name:DIXON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANDA
Other - Middle Name:DAWN
Other - Last Name:SOUTHARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:105 S ELM ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420-9581
Mailing Address - Country:US
Mailing Address - Phone:270-827-7200
Mailing Address - Fax:
Practice Address - Street 1:1305 N ELM ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2783
Practice Address - Country:US
Practice Address - Phone:270-827-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-22
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007749363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner