Provider Demographics
NPI:1245240969
Name:WOLICKI-SHANNON, JOANNA (MD)
Entity Type:Individual
Prefix:MRS
First Name:JOANNA
Middle Name:
Last Name:WOLICKI-SHANNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 NORTH QUEEN STREET
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-1581
Mailing Address - Country:US
Mailing Address - Phone:252-523-2781
Mailing Address - Fax:252-523-2711
Practice Address - Street 1:1305 NORTH QUEEN STREET
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-1581
Practice Address - Country:US
Practice Address - Phone:252-523-2781
Practice Address - Fax:252-523-2711
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2000010332084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCH44184Medicare UPIN