Provider Demographics
NPI:1770745879
Name:SHELLEY, SHANNON FRANKLIN (OD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:FRANKLIN
Last Name:SHELLEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:TN
Mailing Address - Zip Code:38583-2063
Mailing Address - Country:US
Mailing Address - Phone:931-836-2235
Mailing Address - Fax:931-836-3036
Practice Address - Street 1:25 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:TN
Practice Address - Zip Code:38583-2063
Practice Address - Country:US
Practice Address - Phone:931-836-2235
Practice Address - Fax:931-836-3036
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2809152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1507008Medicaid
TN6184510001Medicare NSC
TN35900801Medicare PIN