Provider Demographics
NPI:1598308389
Name:PARKS, SHANNON D (APN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:D
Last Name:PARKS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOYLETON
Mailing Address - State:IL
Mailing Address - Zip Code:62803-2046
Mailing Address - Country:US
Mailing Address - Phone:618-314-6266
Mailing Address - Fax:
Practice Address - Street 1:620 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HOYLETON
Practice Address - State:IL
Practice Address - Zip Code:62803-2046
Practice Address - Country:US
Practice Address - Phone:618-314-6266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020223363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily