Provider Demographics
NPI:1043013394
Name:BLACK, SHANNON (FNP-BC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BLACK
Suffix:
Gender:
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 1:3992 COUNTY ROAD 7960
Mailing Address - Street 2:
Mailing Address - City:MOODY
Mailing Address - State:MO
Mailing Address - Zip Code:65777-9803
Mailing Address - Country:US
Mailing Address - Phone:417-257-4414
Mailing Address - Fax:
Practice Address - Street 1:3992 COUNTY ROAD 7960
Practice Address - Street 2:
Practice Address - City:MOODY
Practice Address - State:MO
Practice Address - Zip Code:65777-9803
Practice Address - Country:US
Practice Address - Phone:417-257-4414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2025004733207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine