Provider Demographics
NPI:1558463885
Name:DOOLEY, SHANNON MALENA (N P)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MALENA
Last Name:DOOLEY
Suffix:
Gender:F
Credentials:N P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 W LONGEST ST
Mailing Address - Street 2:PO BOX 270
Mailing Address - City:PAOLI
Mailing Address - State:IN
Mailing Address - Zip Code:47454-8821
Mailing Address - Country:US
Mailing Address - Phone:812-723-7993
Mailing Address - Fax:812-723-7991
Practice Address - Street 1:420 W LONGEST ST
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:IN
Practice Address - Zip Code:47454-8821
Practice Address - Country:US
Practice Address - Phone:812-723-3944
Practice Address - Fax:812-723-5292
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001609A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200452120AMedicaid
INP99255Medicare UPIN
IN200452120AMedicaid
IN600340RMedicare PIN