Provider Demographics
NPI:1164094967
Name:SHANNON, NICHOLLE ELIZABETH (CRNP)
Entity Type:Individual
Prefix:
First Name:NICHOLLE
Middle Name:ELIZABETH
Last Name:SHANNON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:NICHOLLE
Other - Middle Name:ELIZABETH
Other - Last Name:DALEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5445 LANARK RD FL 3
Mailing Address - Street 2:
Mailing Address - City:CENTER VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:18034-8694
Mailing Address - Country:US
Mailing Address - Phone:484-526-7300
Mailing Address - Fax:866-449-5832
Practice Address - Street 1:5445 LANARK RD FL 3
Practice Address - Street 2:
Practice Address - City:CENTER VALLEY
Practice Address - State:PA
Practice Address - Zip Code:18034-8694
Practice Address - Country:US
Practice Address - Phone:484-526-7300
Practice Address - Fax:866-449-5832
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN673311363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner