Provider Demographics
NPI:1801199070
Name:GAVIN, SHANNON MICHELE (MSN, RN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MICHELE
Last Name:GAVIN
Suffix:
Gender:F
Credentials:MSN, RN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1430
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-9230
Mailing Address - Country:US
Mailing Address - Phone:219-764-3251
Mailing Address - Fax:219-764-3251
Practice Address - Street 1:407 W INDIANA AVE
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-2350
Practice Address - Country:US
Practice Address - Phone:219-763-8112
Practice Address - Fax:219-764-5384
Is Sole Proprietor?:No
Enumeration Date:2010-12-09
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2010007825363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201015570Medicaid
IN71003579AOtherLICENSE
IN201015570Medicaid