Provider Demographics
NPI:1356502389
Name:HANSEN COOK, SHANNON (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HANSEN COOK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:L
Other - Last Name:HANSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:917 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6527
Practice Address - Country:US
Practice Address - Phone:423-439-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL308942084P0800X
TN533152084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ065146Medicaid