Provider Demographics
NPI:1871316265
Name:SHANNON, BRENDA
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:SHANNON
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 1:1000 LEGACY RANCH RD
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-1293
Mailing Address - Country:US
Mailing Address - Phone:877-868-2528
Mailing Address - Fax:877-926-5332
Practice Address - Street 1:1000 LEGACY RANCH RD
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-1293
Practice Address - Country:US
Practice Address - Phone:877-868-2528
Practice Address - Fax:877-926-5332
Is Sole Proprietor?:No
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1047242363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily