Provider Demographics
NPI:1619593241
Name:KELLY, SHANNON MARIE (RN)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:HANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3400 N WOODS LN
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-6712
Mailing Address - Country:US
Mailing Address - Phone:479-636-3190
Mailing Address - Fax:
Practice Address - Street 1:3400 N WOODS LN
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-6712
Practice Address - Country:US
Practice Address - Phone:479-685-6196
Practice Address - Fax:479-636-4587
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR054648163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse