Basic Information
| Provider Information | |||||||||
| NPI: | 1255705281 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | MCDONNELL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TAYLOR | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | ASHLEY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 79777 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212790777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4346547794 | ||||||||
| FaxNumber: | 4346547752 | ||||||||
| Practice Location | |||||||||
| Address1: | 29 JEFFERSON CT | ||||||||
| Address2: | |||||||||
| City: | ZION CROSSROADS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229429602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4346548900 | ||||||||
| FaxNumber: | 5408321728 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2015 | ||||||||
| LastUpdateDate: | 06/06/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 0001226713 | VA | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 0024174550 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.