Provider Demographics
NPI:1598304115
Name:LEAKE, SHANNON D (APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:D
Last Name:LEAKE
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 COUNTY ROAD 1612
Mailing Address - Street 2:410 NORTH JEFFERSON AVENUE #262
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:TX
Mailing Address - Zip Code:75455-3937
Mailing Address - Country:US
Mailing Address - Phone:903-287-5788
Mailing Address - Fax:
Practice Address - Street 1:410 N JEFFERSON AVE # 262
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455-3937
Practice Address - Country:US
Practice Address - Phone:903-287-5788
Practice Address - Fax:903-213-9031
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-30
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP144577363LF0000X
NM63678363LF0000X
CO0002825-C-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM63678OtherNEW MEXICO BOARD OF NURSING
CO0002825-C-NPOtherCOLORADO DEPARTMENT OF REGULATORY AGENCIES DIVISION OF PROFESSIONS AND OCCUPATIO
TXAP144577OtherTEXAS BON