Provider Demographics
NPI:1265803399
Name:MILLSAPS, SHANNON GAIL (RN, MSN, AGACNP-BC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:GAIL
Last Name:MILLSAPS
Suffix:
Gender:F
Credentials:RN, MSN, AGACNP-BC
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MILLSAPS
Other - Last Name:LANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 604050
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-4050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2030 HAMILTON PLACE BLVD STE 220
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-6040
Practice Address - Country:US
Practice Address - Phone:423-553-1823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC158203363L00000X
NC5008025363L00000X, 363LA2100X, 363LA2200X
TN33626363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCP943AMedicare Oscar/Certification