Provider Demographics
NPI:1639787245
Name:BROOKS, SHANNON LYNN (APRN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LYNN
Last Name:BROOKS
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 1:314 BRAEBURN DR
Mailing Address - Street 2:
Mailing Address - City:BROOKS
Mailing Address - State:KY
Mailing Address - Zip Code:40109-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:170 DR ARLA WAY STE 101
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40229-5427
Practice Address - Country:US
Practice Address - Phone:502-955-8480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY19765207Q00000X
KY3014491363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine