Provider Demographics
NPI:1609498427
Name:MATT, SHAWNA M (APRN)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:M
Last Name:MATT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6603 LEVEN CT
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-2378
Mailing Address - Country:US
Mailing Address - Phone:502-551-3762
Mailing Address - Fax:
Practice Address - Street 1:3615 E JOHN ROWAN BLVD STE 104
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-3264
Practice Address - Country:US
Practice Address - Phone:502-331-4734
Practice Address - Fax:270-706-5802
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-14
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3014102363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily