Basic Information
| Provider Information | |||||||||
| NPI: | 1295101186 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUNNELS | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | AMBER | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1340 HAL GREER BLVD | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257013804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043996727 | ||||||||
| FaxNumber: | 3043996726 | ||||||||
| Practice Location | |||||||||
| Address1: | 1340 HAL GREER BLVD | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257013804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043996727 | ||||||||
| FaxNumber: | 3043996726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2015 | ||||||||
| LastUpdateDate: | 04/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3009339 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 101120 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1295101186 | 05 | WV | MEDICAID | 7100463850 | 05 | KY | MEDICAID | 0263765 | 05 | OH | MEDICAID |