Provider Demographics
NPI:1346958279
Name:PEMBERTON, SHANNON SUMMER (PMHNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:SUMMER
Last Name:PEMBERTON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 PRIVATE DRIVE 11202 UNIT 3
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:OH
Mailing Address - Zip Code:45619-7014
Mailing Address - Country:US
Mailing Address - Phone:304-617-7999
Mailing Address - Fax:
Practice Address - Street 1:6171 CHILDERS RD
Practice Address - Street 2:
Practice Address - City:BARBOURSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25504-1227
Practice Address - Country:US
Practice Address - Phone:304-733-5380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3018645363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health