Provider Demographics
NPI:1386480473
Name:SMITH, SHANNAN LEA (MSN, APRN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:SHANNAN
Middle Name:LEA
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSN, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:SHANNAN
Other - Middle Name:LEA
Other - Last Name:WILLMAN-NEEDLEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN, RN
Mailing Address - Street 1:560 N KIMBALL AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6879
Mailing Address - Country:US
Mailing Address - Phone:817-899-8485
Mailing Address - Fax:
Practice Address - Street 1:560 N KIMBALL AVE STE 130
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6879
Practice Address - Country:US
Practice Address - Phone:817-899-8485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1168185363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health