Provider Demographics
NPI:1083331763
Name:KEITH, SHANNON MARIA
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MARIA
Last Name:KEITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 GREENE ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29208-4001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 HOSPITAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:HILTON HEAD
Practice Address - State:SC
Practice Address - Zip Code:29926-2738
Practice Address - Country:US
Practice Address - Phone:843-681-6122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC27405363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program