Provider Demographics
NPI:1336596121
Name:SULLIVAN-EVANS, SHANNON (FNP-BC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SULLIVAN-EVANS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:COLLEEN
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:423 MEDICAL PARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LENOIR CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37772-5641
Mailing Address - Country:US
Mailing Address - Phone:865-271-6600
Mailing Address - Fax:865-374-2102
Practice Address - Street 1:423 MEDICAL PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37772-5641
Practice Address - Country:US
Practice Address - Phone:865-271-6600
Practice Address - Fax:865-374-2102
Is Sole Proprietor?:No
Enumeration Date:2016-05-21
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN96411163W00000X
TNAPN21230363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ022325Medicaid