Provider Demographics
NPI:1255374880
Name:ROBERTS, SHANNON LEIGH (NP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEIGH
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1225 E WEISGARBER RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-2604
Mailing Address - Country:US
Mailing Address - Phone:865-584-4747
Mailing Address - Fax:865-584-1363
Practice Address - Street 1:7744 CONNER RD
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-3509
Practice Address - Country:US
Practice Address - Phone:865-546-9751
Practice Address - Fax:865-362-6681
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN7578363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3344360Medicare PIN
P50657Medicare UPIN