Provider Demographics
NPI:1992997415
Name:SHANAHAN, TONYA D
Entity type:Individual
Prefix:
First Name:TONYA
Middle Name:D
Last Name:SHANAHAN
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:PO BOX 2400
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35403-2400
Mailing Address - Country:US
Mailing Address - Phone:205-614-6102
Mailing Address - Fax:
Practice Address - Street 1:2731 MLK JR BLVD
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-5235
Practice Address - Country:US
Practice Address - Phone:205-349-3250
Practice Address - Fax:205-345-3993
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1082093363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL104109Medicaid
AL515-93760OtherBCBS/AL
AL104109Medicaid