Basic Information
| Provider Information | |||||||||
| NPI: | 1558909176 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHANNON | ||||||||
| FirstName: | MICHELLE | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 MANSFIELD CT | ||||||||
| Address2: | |||||||||
| City: | SEVERNA PARK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211461724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4438676894 | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | GLEN BURNIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210615803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107874565 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2019 | ||||||||
| LastUpdateDate: | 12/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/13/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LC0200X | R169142 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Critical Care Medicine |
No ID Information.