Provider Demographics
NPI:1427466960
Name:SMITH, SHANNON KELI (FNP-BC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:KELI
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4350 FM 47
Mailing Address - Street 2:
Mailing Address - City:WILLS POINT
Mailing Address - State:TX
Mailing Address - Zip Code:75169-6741
Mailing Address - Country:US
Mailing Address - Phone:469-371-6896
Mailing Address - Fax:
Practice Address - Street 1:775 E US HIGHWAY 80
Practice Address - Street 2:
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP126069363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily