Provider Demographics
NPI:1053792259
Name:MARSDEN, SHANNON NICOLE (MD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:MARSDEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1423 N JEFFERSON AVE STE B100
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-1917
Mailing Address - Country:US
Mailing Address - Phone:417-269-8817
Mailing Address - Fax:417-269-8744
Practice Address - Street 1:1307 PORTER WAGONER BLVD
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-1828
Practice Address - Country:US
Practice Address - Phone:417-255-8645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-12
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015016244207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200050408Medicaid