Provider Demographics
NPI:1477838217
Name:DAVIS, SHANNON GALE (APRN CNP FAMILY)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:GALE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:APRN CNP FAMILY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3414 NW 135TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-4009
Mailing Address - Country:US
Mailing Address - Phone:405-749-0900
Mailing Address - Fax:405-749-0913
Practice Address - Street 1:3414 NW 135TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-4009
Practice Address - Country:US
Practice Address - Phone:405-749-0900
Practice Address - Fax:405-749-0913
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-12
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0069234363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKR0069234OtherSTATE LICENSE
OK200437870AMedicaid
OKOKAAA2766Medicare PIN