Provider Demographics
NPI:1316566607
Name:BUSBY, SHANNON (NP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BUSBY
Suffix:
Gender:F
Credentials:NP
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 9178
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-9178
Mailing Address - Country:US
Mailing Address - Phone:855-498-6767
Mailing Address - Fax:479-968-1673
Practice Address - Street 1:1505 WINTERBROOK DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-3564
Practice Address - Country:US
Practice Address - Phone:479-498-6747
Practice Address - Fax:479-968-1673
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-16
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR124199363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily