Provider Demographics
NPI:1508261702
Name:DAVIS, SHANNON REA (NP-C , PMHNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:REA
Last Name:DAVIS
Suffix:
Gender:F
Credentials:NP-C , PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 772852
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-2852
Mailing Address - Country:US
Mailing Address - Phone:907-696-0096
Mailing Address - Fax:949-577-4808
Practice Address - Street 1:17051 MERCY DR STE 204
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7630
Practice Address - Country:US
Practice Address - Phone:907-696-0096
Practice Address - Fax:949-577-4808
Is Sole Proprietor?:No
Enumeration Date:2014-10-30
Last Update Date:2024-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK148870363LF0000X, 363LP0808X, 363LP0808X
TN21452363L00000X
WAAP61119130363LP0808X
AZ243410363LP0808X
MT233985363LP0808X
OR202105062NPPP363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner