Provider Demographics
NPI:1497868186
Name:SHANNON, WENDY LORRAINE (FNP-C)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:LORRAINE
Last Name:SHANNON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:MRS
Other - First Name:WENDY
Other - Middle Name:LORRAINE
Other - Last Name:SHANNON-HARDEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP-C
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8300 E 96TH ST
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-9795
Practice Address - Country:US
Practice Address - Phone:317-621-1290
Practice Address - Fax:317-621-1291
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000333A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200190000Medicaid
INM400053950Medicare PIN
INM400038557Medicare PIN
IN200190000Medicaid
INM400038564Medicare PIN
INM400038497Medicare PIN
INS85765Medicare UPIN
INM400038492Medicare PIN
INM400038503Medicare PIN
M400023146Medicare PIN