Basic Information
| Provider Information | |||||||||
| NPI: | 1275524423 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUNNINGHAM | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 71230 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191766230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033836469 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8501 ARLINGTON BLVD | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220324625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038105219 | ||||||||
| FaxNumber: | 7038105406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 01/25/2012 | ||||||||
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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 | 367500000X | R083823 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 430074296 | 01 | MD | RR MEDICARE | OTHER | 4191757 00 | 05 | MD | MEDICAID | KBC1CH | 01 | MD | CAREFIRST BCBS | OTHER | S417-0011 | 01 | DC | CAREFIRST BCBS | OTHER |