Provider Demographics
NPI:1083250906
Name:LEIGH, SHANNON (CRNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:LEIGH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 OLIVER HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5073
Mailing Address - Country:US
Mailing Address - Phone:443-310-4552
Mailing Address - Fax:
Practice Address - Street 1:5505 RITCHIE HWY STE E
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:MD
Practice Address - Zip Code:21225-3481
Practice Address - Country:US
Practice Address - Phone:410-355-0340
Practice Address - Fax:410-636-3403
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-26
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR167945363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily