Provider Demographics
NPI:1619033404
Name:WRIGHT, SHANNON RENAE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:RENAE
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1027
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65102-1027
Mailing Address - Country:US
Mailing Address - Phone:573-761-7246
Mailing Address - Fax:573-761-6947
Practice Address - Street 1:100 HIGHWAY 28 W
Practice Address - Street 2:
Practice Address - City:BELLE
Practice Address - State:MO
Practice Address - Zip Code:65013-3405
Practice Address - Country:US
Practice Address - Phone:573-859-3775
Practice Address - Fax:573-859-3997
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO155084363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1619033404Medicaid
MO833883180Medicare PIN