Provider Demographics
NPI:1184029720
Name:REVIT, SHANNON (DNP, FNP-BC, RN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:REVIT
Suffix:
Gender:F
Credentials:DNP, FNP-BC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-5509
Mailing Address - Country:US
Mailing Address - Phone:410-996-8990
Mailing Address - Fax:410-996-8992
Practice Address - Street 1:104 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-5509
Practice Address - Country:US
Practice Address - Phone:410-996-8990
Practice Address - Fax:410-996-8992
Is Sole Proprietor?:No
Enumeration Date:2014-10-24
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR230122363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1184029720Medicaid