Provider Demographics
NPI:1316211600
Name:BRADY-BARDSHER, SHANNON RENEE (ARNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:RENEE
Last Name:BRADY-BARDSHER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 W IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-2738
Mailing Address - Country:US
Mailing Address - Phone:405-779-2834
Mailing Address - Fax:
Practice Address - Street 1:2220 W IOWA AVE
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-2738
Practice Address - Country:US
Practice Address - Phone:405-779-2834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-03
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK83612363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200452510AMedicaid