Provider Demographics
NPI:1619708633
Name:BURCHETT, SHANNON DALE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:DALE
Last Name:BURCHETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:DALE
Other - Last Name:AUXIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2529 GLENN HENDREN DR STE 202
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-9602
Mailing Address - Country:US
Mailing Address - Phone:816-781-8400
Mailing Address - Fax:816-781-8263
Practice Address - Street 1:1950 DIAMOND PKWY
Practice Address - Street 2:
Practice Address - City:NORTH KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116-4328
Practice Address - Country:US
Practice Address - Phone:816-842-6717
Practice Address - Fax:816-842-2574
Is Sole Proprietor?:No
Enumeration Date:2024-08-12
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024009618363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily