Provider Demographics
NPI:1548492952
Name:RUTHERFORD, SHANNON (NP-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:RUTHERFORD
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:WILDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:WHITESBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41858-0040
Mailing Address - Country:US
Mailing Address - Phone:606-633-4823
Mailing Address - Fax:606-633-1874
Practice Address - Street 1:132 VILLAGE CENTER RD
Practice Address - Street 2:
Practice Address - City:HARLAN
Practice Address - State:KY
Practice Address - Zip Code:40831-1777
Practice Address - Country:US
Practice Address - Phone:606-573-7771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006169363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health