Basic Information
| Provider Information | |||||||||
| NPI: | 1518383223 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHANNON | ||||||||
| FirstName: | ROBIN | ||||||||
| MiddleName: | SUE | ||||||||
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| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 MAIN ST STE 15 | ||||||||
| Address2: | |||||||||
| City: | WALPOLE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020813753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086601666 | ||||||||
| FaxNumber: | 5086601667 | ||||||||
| Practice Location | |||||||||
| Address1: | 420 MAIN ST STE 15 | ||||||||
| Address2: | |||||||||
| City: | WALPOLE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020813753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086601666 | ||||||||
| FaxNumber: | 5086601667 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2014 | ||||||||
| LastUpdateDate: | 10/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5006766 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 5006766 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | RN2326129 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1518383223 | 05 | NC | MEDICAID | NP4339 | 05 | SC | MEDICAID |