Provider Demographics
NPI:1316658982
Name:EVERITT, SHANNON YVETTE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:YVETTE
Last Name:EVERITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 N WINNEBAGO DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WINNEBAGO
Mailing Address - State:MO
Mailing Address - Zip Code:64034-9419
Mailing Address - Country:US
Mailing Address - Phone:985-710-3202
Mailing Address - Fax:
Practice Address - Street 1:1707 E CEDAR ST STE 102
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66062-1886
Practice Address - Country:US
Practice Address - Phone:816-977-3178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201121410AMedicaid