Provider Demographics
NPI:1669665964
Name:MITCHELL, SHANNON LARIE (RN-ACNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LARIE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:RN-ACNP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:LARIE
Other - Last Name:HUMPHREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, ACNP
Mailing Address - Street 1:5002 COWHORN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-9766
Mailing Address - Country:US
Mailing Address - Phone:903-614-3000
Mailing Address - Fax:903-614-3525
Practice Address - Street 1:5002 COWHORN CREEK RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-9766
Practice Address - Country:US
Practice Address - Phone:903-614-3000
Practice Address - Fax:903-614-3525
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX653277363LA2100X
TXAP115188363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP115188OtherAPRN
TX653277OtherRN