Provider Demographics
NPI:1982145975
Name:WILES, SHANNON (APRN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WILES
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 TECHWOOD DR N
Mailing Address - Street 2:STE 100
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-8500
Mailing Address - Country:US
Mailing Address - Phone:859-936-9844
Mailing Address - Fax:859-236-0320
Practice Address - Street 1:520 TECHWOOD DR N
Practice Address - Street 2:STE 100
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-8500
Practice Address - Country:US
Practice Address - Phone:859-936-9844
Practice Address - Fax:859-236-0320
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-10
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011177363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily