Provider Demographics
NPI:1548916810
Name:SHACONYA L RICHARDSON
Entity type:Organization
Organization Name:SHACONYA L RICHARDSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-654-3927
Mailing Address - Street 1:6007 COUNT TURF DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40272-3549
Mailing Address - Country:US
Mailing Address - Phone:502-243-5565
Mailing Address - Fax:
Practice Address - Street 1:714 LYNDON LN STE 6
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4643
Practice Address - Country:US
Practice Address - Phone:502-225-4900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty