Provider Demographics
NPI:1841673753
Name:WITT, SHANNON (FNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WITT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:1002 CATALPA DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47122-8785
Mailing Address - Country:US
Mailing Address - Phone:812-913-3818
Mailing Address - Fax:812-590-3168
Practice Address - Street 1:2708 PAOLI PIKE STE I
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-5100
Practice Address - Country:US
Practice Address - Phone:812-725-7894
Practice Address - Fax:812-590-3168
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-09
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1111715363LP2300X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine