Basic Information
| Provider Information | |||||||||
| NPI: | 1033101928 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHANAHAN | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | C.R.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 BENFIELD BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MILLERSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211083002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107295100 | ||||||||
| FaxNumber: | 4107295156 | ||||||||
| Practice Location | |||||||||
| Address1: | 7556 TEAGUE ROAD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | HANOVER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105510499 | ||||||||
| FaxNumber: | 4107999070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2005 | ||||||||
| LastUpdateDate: | 03/12/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | R121329 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 641932-02 | 01 | MD | CAREFIRST MD RENDERING OD | OTHER | 405743100 | 05 | MD | MEDICAID | 7605-0067 | 01 | MD | CAREFIRST BLUECHOICE | OTHER | 107916 | 01 | MD | JHHC PROVIDER NUMBER | OTHER |