Provider Demographics
NPI:1073174264
Name:MACDONALD, SHANNON LYNN (AUD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LYNN
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:L
Other - Last Name:MCKINNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8924 BLAKENEY PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-6660
Mailing Address - Country:US
Mailing Address - Phone:704-703-1080
Mailing Address - Fax:704-703-1090
Practice Address - Street 1:8924 BLAKENEY PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-6660
Practice Address - Country:US
Practice Address - Phone:704-703-1080
Practice Address - Fax:704-703-1090
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-27
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
231H00000X
NC13654231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC13654OtherN.C. BOARD OF EXAMINERS AUDIOLOGIST LICENSE