Provider Demographics
NPI:1164750105
Name:CHURCH, SHANNON L (PA)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:L
Last Name:CHURCH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:L
Other - Last Name:LAMBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:271 CAREW ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-2377
Mailing Address - Country:US
Mailing Address - Phone:413-748-9349
Mailing Address - Fax:413-452-6080
Practice Address - Street 1:271 CAREW ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-2377
Practice Address - Country:US
Practice Address - Phone:413-748-9349
Practice Address - Fax:413-452-6080
Is Sole Proprietor?:No
Enumeration Date:2009-12-03
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA3911363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPA3911OtherMA PA LICENSE