Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LC0200X | Nurse Practitioner - Critical Care Medicine | R169142 | MD |
NPI | 1558909176 |
---|---|
Provider Name | Michelle Shannon |
First Address | Severna Park, MD 21146-1724 |
Second Address | Glen Burnie, MD 21061-5803 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/12/2019 |
Last Update Date | 13/12/2019 |