Provider Demographics
NPI:1669788204
Name:CHILDERS-PAGE, SHANNON L (CNS)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:CHILDERS-PAGE
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:L
Other - Last Name:PAGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNS
Mailing Address - Street 1:461 TOWN CENTER ST N
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46158-2316
Mailing Address - Country:US
Mailing Address - Phone:317-497-6700
Mailing Address - Fax:317-497-6711
Practice Address - Street 1:1701 N SENATE BLVD # A5231
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:317-962-1429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-20
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003354A363LA2200X
IN28123065A364SA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200996380Medicaid
INM400035726Medicare PIN
INM400028871Medicare PIN