Provider Demographics
NPI:1508292210
Name:SHANNON G. DAVIS, APRN-CNP FAMILY, P.L.L.C
Entity Type:Organization
Organization Name:SHANNON G. DAVIS, APRN-CNP FAMILY, P.L.L.C
Other - Org Name:THE YALE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:GALE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-CNP
Authorized Official - Phone:405-414-1441
Mailing Address - Street 1:3414 NW 135TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-4009
Mailing Address - Country:US
Mailing Address - Phone:405-749-0900
Mailing Address - Fax:405-749-0913
Practice Address - Street 1:3414 NW 135TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-4009
Practice Address - Country:US
Practice Address - Phone:405-414-1441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-25
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR69234261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200437870AMedicaid
OKOKAAA2766Medicare PIN