Provider Demographics
NPI:1932293362
Name:BURNETTE, SHANNON (RN,MSN)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:BURNETTE
Suffix:
Gender:F
Credentials:RN,MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 KENTUCKY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-4257
Mailing Address - Country:US
Mailing Address - Phone:217-223-0423
Mailing Address - Fax:217-223-0461
Practice Address - Street 1:4409 MAINE ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-5849
Practice Address - Country:US
Practice Address - Phone:217-223-0423
Practice Address - Fax:217-223-0461
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2005010932364SP0809X
IL163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health