Provider Demographics
NPI:1043013394
Name:BLACK, SHANNON (FNP-BC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
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 1:4196 HIGHWAY 62 412 STE A
Mailing Address - Street 2:
Mailing Address - City:HARDY
Mailing Address - State:AR
Mailing Address - Zip Code:72542-8002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:942 HIGHWAY 65 N
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:AR
Practice Address - Zip Code:72650-7772
Practice Address - Country:US
Practice Address - Phone:888-518-1418
Practice Address - Fax:501-468-0468
Is Sole Proprietor?:No
Enumeration Date:2025-03-31
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2025004733207Q00000X
AR233849363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine