Provider Demographics
NPI:1134699440
Name:VANDEVOORDT, SHANNON (RN, CLC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:VANDEVOORDT
Suffix:
Gender:F
Credentials:RN, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 E 2ND ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-2317
Mailing Address - Country:US
Mailing Address - Phone:857-496-5095
Mailing Address - Fax:
Practice Address - Street 1:387 W BROADWAY
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-2217
Practice Address - Country:US
Practice Address - Phone:857-496-5095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2268347163WM0102X
MACLC78333163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn