Provider Demographics
NPI:1245788116
Name:PENNINGTON, SHANON
Entity Type:Individual
Prefix:
First Name:SHANON
Middle Name:
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 BREAKWATER BAY
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076-3675
Mailing Address - Country:US
Mailing Address - Phone:615-414-8195
Mailing Address - Fax:
Practice Address - Street 1:125 BREAKWATER BAY
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-3675
Practice Address - Country:US
Practice Address - Phone:615-414-8195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-20
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1-16-22235103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst