Provider Demographics
NPI:1659159564
Name:LAVENDER, SHANNON TAYLOR (MSN, FNP-C)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:TAYLOR
Last Name:LAVENDER
Suffix:
Gender:F
Credentials:MSN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4825 MACCORKLE AVE SW STE A
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1365
Mailing Address - Country:US
Mailing Address - Phone:304-400-4700
Mailing Address - Fax:304-400-4635
Practice Address - Street 1:4825 MACCORKLE AVE SW STE A
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1365
Practice Address - Country:US
Practice Address - Phone:304-400-4700
Practice Address - Fax:304-400-4635
Is Sole Proprietor?:No
Enumeration Date:2023-09-20
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV104481163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse