Provider Demographics
NPI:1407697709
Name:IRISH, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:IRISH
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 1:4245 PLEASANT RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056-8601
Mailing Address - Country:US
Mailing Address - Phone:606-584-1224
Mailing Address - Fax:
Practice Address - Street 1:4245 PLEASANT RIDGE RD
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-8601
Practice Address - Country:US
Practice Address - Phone:606-584-1224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-03
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4021528363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily