Provider Demographics
NPI:1942712310
Name:WILLIAMS, SHANNON MARIE (NP-C, FNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:NP-C, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 959203
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-2314
Mailing Address - Country:US
Mailing Address - Phone:618-767-3235
Mailing Address - Fax:618-624-4992
Practice Address - Street 1:9515 HOLY CROSS LN STE 175
Practice Address - Street 2:
Practice Address - City:BREESE
Practice Address - State:IL
Practice Address - Zip Code:62230-3618
Practice Address - Country:US
Practice Address - Phone:618-526-8430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-25
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017001325363L00000X
IL209015851363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily