Provider Demographics
NPI:1194364349
Name:SHAUGHNESSY, KIMBERLY LYNN
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LYNN
Last Name:SHAUGHNESSY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3019 FLINT HILL RD
Mailing Address - Street 2:
Mailing Address - City:ADAMSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21710-9210
Mailing Address - Country:US
Mailing Address - Phone:501-940-6986
Mailing Address - Fax:
Practice Address - Street 1:16151 OLD FREDERICK RD
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:MD
Practice Address - Zip Code:21771-3337
Practice Address - Country:US
Practice Address - Phone:410-489-6959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-04
Last Update Date:2020-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01623L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist