Provider Demographics
NPI:1649576562
Name:BUNCH, SHANNON D (APRN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:D
Last Name:BUNCH
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 1:1595 BEE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-8813
Mailing Address - Country:US
Mailing Address - Phone:606-528-6527
Mailing Address - Fax:
Practice Address - Street 1:140 BRYAN BLVD
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-2775
Practice Address - Country:US
Practice Address - Phone:606-523-2005
Practice Address - Fax:606-546-9363
Is Sole Proprietor?:No
Enumeration Date:2011-02-10
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006842363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100166150Medicaid
KYK002020Medicare PIN