Provider Demographics
NPI:1508045840
Name:WHITTEN, SHANNON ETHERIDGE (MS,NP-C, APRN,BC,)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:ETHERIDGE
Last Name:WHITTEN
Suffix:
Gender:F
Credentials:MS,NP-C, APRN,BC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 FERNCREST DR
Mailing Address - Street 2:
Mailing Address - City:SANDERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31082-1863
Mailing Address - Country:US
Mailing Address - Phone:478-864-3448
Mailing Address - Fax:478-864-1288
Practice Address - Street 1:616 FERNCREST DR
Practice Address - Street 2:
Practice Address - City:SANDERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31082-1863
Practice Address - Country:US
Practice Address - Phone:478-864-3448
Practice Address - Fax:478-864-1288
Is Sole Proprietor?:No
Enumeration Date:2007-11-02
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR117082363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily