Provider Demographics
NPI:1376003673
Name:CUMMINGS, SHANNON ELIZABETH (OD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:CUMMINGS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:ELIZABETH
Other - Last Name:RENNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4801 S CLIFF AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-6954
Mailing Address - Country:US
Mailing Address - Phone:816-478-1230
Mailing Address - Fax:816-350-4585
Practice Address - Street 1:4801 S CLIFF AVE STE 100
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-6954
Practice Address - Country:US
Practice Address - Phone:816-478-1230
Practice Address - Fax:816-350-4585
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2105152W00000X
390200000X
MO2019026756152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q00037687OtherPALMETTO GBA RAILROAD MEDICARE