Provider Demographics
NPI:1154082212
Name:DAHL, SHANNAN RAE (RN, MT)
Entity Type:Individual
Prefix:
First Name:SHANNAN
Middle Name:RAE
Last Name:DAHL
Suffix:
Gender:F
Credentials:RN, MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 893
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20156-0893
Mailing Address - Country:US
Mailing Address - Phone:703-853-3351
Mailing Address - Fax:
Practice Address - Street 1:13801 BRADDOCK SPRINGS RD APT K
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-4245
Practice Address - Country:US
Practice Address - Phone:703-853-3351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-31
Last Update Date:2021-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019011674225700000X
VA0001298714163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist