Provider Demographics
NPI:1558987248
Name:DAVIS, SHANNON (LPN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 N MYRTLE ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:AR
Mailing Address - Zip Code:71671
Mailing Address - Country:US
Mailing Address - Phone:870-250-0805
Mailing Address - Fax:
Practice Address - Street 1:790 ROBERTS DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-5723
Practice Address - Country:US
Practice Address - Phone:870-367-2461
Practice Address - Fax:870-460-6133
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-18
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator