Provider Demographics
NPI:1073984449
Name:ADAMS, SHANNON SHANELL
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:SHANELL
Last Name:ADAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:SHANELL
Other - Last Name:ADAMS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1150 MOUNT OLIVET RD
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-6033
Mailing Address - Country:US
Mailing Address - Phone:276-634-7388
Mailing Address - Fax:276-632-7693
Practice Address - Street 1:1150 MOUNT OLIVET RD
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-6033
Practice Address - Country:US
Practice Address - Phone:276-634-7388
Practice Address - Fax:276-632-7693
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-12
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0178641319Medicaid