Provider Demographics
NPI:1801090444
Name:OLUSANYA, SHAUNDELLE ANN (DNP)
Entity type:Individual
Prefix:
First Name:SHAUNDELLE
Middle Name:ANN
Last Name:OLUSANYA
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 S BISHOP AVE
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-4411
Mailing Address - Country:US
Mailing Address - Phone:573-426-5900
Mailing Address - Fax:573-426-4466
Practice Address - Street 1:1060 S BISHOP AVE
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-4411
Practice Address - Country:US
Practice Address - Phone:573-426-5900
Practice Address - Fax:573-426-4466
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003014072363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOQ01075Medicare UPIN