Provider Demographics
NPI:1104104090
Name:MIDDLETON, SHAWNA RENEE (FNP-C)
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:RENEE
Last Name:MIDDLETON
Suffix:
Gender:
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4196 HIGHWAY 62 412 STE A
Mailing Address - Street 2:
Mailing Address - City:HARDY
Mailing Address - State:AR
Mailing Address - Zip Code:72542-8002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:49 HIGHWAY 62 412
Practice Address - Street 2:
Practice Address - City:ASH FLAT
Practice Address - State:AR
Practice Address - Zip Code:72513-9594
Practice Address - Country:US
Practice Address - Phone:870-994-7301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-27
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03569363LF0000X, 363LF0000X
MS903074363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1104104090Medicaid
AR189363758Medicaid