Provider Demographics
NPI:1013528033
Name:BRISCOE, SHANNON BROOKE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:BROOKE
Last Name:BRISCOE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 SHADY FORK RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHSIDE
Mailing Address - State:WV
Mailing Address - Zip Code:25187-8891
Mailing Address - Country:US
Mailing Address - Phone:304-812-3925
Mailing Address - Fax:
Practice Address - Street 1:311 SHADY FORK RD
Practice Address - Street 2:
Practice Address - City:SOUTHSIDE
Practice Address - State:WV
Practice Address - Zip Code:25187-8891
Practice Address - Country:US
Practice Address - Phone:304-812-3925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant