Provider Demographics
NPI:1760688469
Name:NILEST, SHANNON M (MED, LPP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:M
Last Name:NILEST
Suffix:
Gender:F
Credentials:MED, LPP
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:M
Other - Last Name:MAHONEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED LPP
Mailing Address - Street 1:101 W MUHAMMAD ALI BLVD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1423
Mailing Address - Country:US
Mailing Address - Phone:502-589-8600
Mailing Address - Fax:
Practice Address - Street 1:4710 CHAMPIONS TRACE LN
Practice Address - Street 2:SUITE 107
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-3495
Practice Address - Country:US
Practice Address - Phone:502-454-6353
Practice Address - Fax:502-459-9209
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-21
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY114308103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist