Provider Demographics
NPI:1295781045
Name:PETERSON, SHANNA B (FNP)
Entity type:Individual
Prefix:MRS
First Name:SHANNA
Middle Name:B
Last Name:PETERSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SHANNA
Other - Middle Name:
Other - Last Name:BARTLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 716
Mailing Address - Street 2:
Mailing Address - City:ERWIN
Mailing Address - State:TN
Mailing Address - Zip Code:37650-0716
Mailing Address - Country:US
Mailing Address - Phone:423-743-3440
Mailing Address - Fax:
Practice Address - Street 1:1201 N MAIN AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:ERWIN
Practice Address - State:TN
Practice Address - Zip Code:37650-9102
Practice Address - Country:US
Practice Address - Phone:423-743-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN11999363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4131091OtherBCBST
TN3643493Medicaid
TN4131091OtherBCBS
TN3643493Medicaid
TN4131091OtherBCBS
Q71630Medicare UPIN
3703865Medicare PIN