Provider Demographics
NPI:1316212673
Name:COOK, SHANNON RENEE (NP-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:RENEE
Last Name:COOK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 MEDICAL PARK DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-1100
Mailing Address - Country:US
Mailing Address - Phone:276-378-3300
Mailing Address - Fax:276-378-1265
Practice Address - Street 1:245 MEDICAL PARK DR
Practice Address - Street 2:SUITE C
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-1100
Practice Address - Country:US
Practice Address - Phone:276-378-3300
Practice Address - Fax:276-378-1265
Is Sole Proprietor?:No
Enumeration Date:2012-03-19
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024169951363LF0000X
TN19716363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1316212673Medicaid
TNQ010323Medicaid
VA1316212673Medicaid
VAVV6952AMedicare PIN