Provider Demographics
NPI:1225649742
Name:HENRY, SHANNON KENDRA (CPNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:KENDRA
Last Name:HENRY
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 BRIDGER DR
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23430-6381
Mailing Address - Country:US
Mailing Address - Phone:757-677-6467
Mailing Address - Fax:
Practice Address - Street 1:733 VOLVO PKWY STE 200
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-1609
Practice Address - Country:US
Practice Address - Phone:757-547-5851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024179769208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics