Provider Demographics
NPI:1396315966
Name:HORSTMAN, SHANNON RAE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:RAE
Last Name:HORSTMAN
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 1:2120 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-4437
Mailing Address - Country:US
Mailing Address - Phone:931-241-8171
Mailing Address - Fax:
Practice Address - Street 1:2690 MADISON ST STE 130
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-6185
Practice Address - Country:US
Practice Address - Phone:931-245-1701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program