Provider Demographics
NPI:1326404245
Name:MILLARD, SHANNEL ANAE
Entity Type:Individual
Prefix:
First Name:SHANNEL
Middle Name:ANAE
Last Name:MILLARD
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 1:2421 NW 94TH ST
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66618-9523
Mailing Address - Country:US
Mailing Address - Phone:785-969-6660
Mailing Address - Fax:
Practice Address - Street 1:600 SW JEWELL AVE
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66606-1607
Practice Address - Country:US
Practice Address - Phone:785-295-5310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-76689-041363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily