Provider Demographics
NPI:1134676877
Name:SHANAHAN, KELLEY B
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:B
Last Name:SHANAHAN
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 1:9600 PATTERSON AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23229-6053
Mailing Address - Country:US
Mailing Address - Phone:804-741-6200
Mailing Address - Fax:804-741-6213
Practice Address - Street 1:9600 PATTERSON AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-6053
Practice Address - Country:US
Practice Address - Phone:804-741-6200
Practice Address - Fax:804-741-6213
Is Sole Proprietor?:No
Enumeration Date:2016-09-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173923363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09633OtherGROUP PTAN
VAC06778OtherGROUP PTAN
VAC06734OtherGROUP PTAN