Provider Demographics
NPI:1962139261
Name:GOINES, SHANNON NICOLE (NP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:GOINES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10529 SPRUCE RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:TN
Mailing Address - Zip Code:38002-8373
Mailing Address - Country:US
Mailing Address - Phone:901-569-8083
Mailing Address - Fax:
Practice Address - Street 1:10529 SPRUCE RIDGE LN
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:TN
Practice Address - Zip Code:38002-8373
Practice Address - Country:US
Practice Address - Phone:901-569-8083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-05
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905907363LF0000X
TN32512363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily