Provider Demographics
NPI:1265086003
Name:OLIVER, SHANNON (NP-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:OLIVER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9320 PARK WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4301
Mailing Address - Country:US
Mailing Address - Phone:865-373-7100
Mailing Address - Fax:865-374-2029
Practice Address - Street 1:9320 PARK WEST BLVD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4301
Practice Address - Country:US
Practice Address - Phone:865-373-7100
Practice Address - Fax:865-374-2029
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25940363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ054759Medicaid