Provider Demographics
NPI:1487342804
Name:RIVERA, SHANNON MARIE (RN)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MARIE
Last Name:RIVERA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:WOOLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:179 CARDINAL LOOP
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-5897
Mailing Address - Country:US
Mailing Address - Phone:931-200-2237
Mailing Address - Fax:
Practice Address - Street 1:1503 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-5967
Practice Address - Country:US
Practice Address - Phone:931-484-6196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN242978163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse