Provider Demographics
NPI:1861538563
Name:COLEMAN, SHANNON ILENE (RN)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:ILENE
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:ILENE
Other - Last Name:MCWATERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:TAYLOR AT MARRION ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29220-0001
Practice Address - Country:US
Practice Address - Phone:803-296-2276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3281367500000X
SC83980163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN1926Medicaid