Provider Demographics
NPI:1295147288
Name:KILLEBREW, SHANNA (PA-C)
Entity type:Individual
Prefix:MISS
First Name:SHANNA
Middle Name:
Last Name:KILLEBREW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6599
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36302-6599
Mailing Address - Country:US
Mailing Address - Phone:334-793-5000
Mailing Address - Fax:334-615-8418
Practice Address - Street 1:4370 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1056
Practice Address - Country:US
Practice Address - Phone:334-793-5000
Practice Address - Fax:334-615-8418
Is Sole Proprietor?:No
Enumeration Date:2014-05-23
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA964363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant