Provider Demographics
NPI:1275509739
Name:HUSSEY, SHANNON R (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:R
Last Name:HUSSEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3439
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-0439
Mailing Address - Country:US
Mailing Address - Phone:843-839-4447
Mailing Address - Fax:843-399-0123
Practice Address - Street 1:3361 HIGHWAY 9 E
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-7826
Practice Address - Country:US
Practice Address - Phone:843-497-5929
Practice Address - Fax:866-778-9612
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCR 690504363LF0000X
SC846207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC136604Medicaid
SC136604Medicaid
SCSC20808383Medicare PIN