Basic Information
| Provider Information | |||||||||
| NPI: | 1710372511 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROCKMAN | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | MD, RDN, FAAP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 620 JOHN PAUL JONES CIR | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237082111 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 620 JOHN PAUL JONES CIR | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237082111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579535000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2015 | ||||||||
| LastUpdateDate: | 08/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 0101261265 | VA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0101261265 | 01 | VA | MEDICAL LICENSE | OTHER |