Provider Demographics
NPI:1215599170
Name:CARROLL, SHANNON JOAN (NP-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:JOAN
Last Name:CARROLL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1448 RICHARDSON ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-5322
Mailing Address - Country:US
Mailing Address - Phone:301-648-4545
Mailing Address - Fax:
Practice Address - Street 1:1448 RICHARDSON ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-5322
Practice Address - Country:US
Practice Address - Phone:301-648-4545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-01
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR198017363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR198017OtherREGISTERED NURSE LICENSE
MDR198017OtherNURSE PRACTITIONER LICENSE