Provider Demographics
NPI:1407814866
Name:COLTER, SHANNON L (NP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:L
Last Name:COLTER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:L
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8075 N SHADELAND AVE
Practice Address - Street 2:#350
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2693
Practice Address - Country:US
Practice Address - Phone:317-678-3900
Practice Address - Fax:317-841-0395
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001958A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200824730Medicaid
INQ56195Medicare UPIN
INP01283398Medicare PIN
IN218650KMedicare PIN
IN200824730Medicaid
IN264430059Medicare PIN