Provider Demographics
NPI:1275524423
Name:CUNNINGHAM, SHANNON M (CRNA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 71230
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19176-6230
Mailing Address - Country:US
Mailing Address - Phone:703-383-6469
Mailing Address - Fax:
Practice Address - Street 1:8501 ARLINGTON BLVD
Practice Address - Street 2:SUITE 550
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22032-4625
Practice Address - Country:US
Practice Address - Phone:703-810-5219
Practice Address - Fax:703-810-5406
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR083823367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD430074296OtherRR MEDICARE
MD4191757 00Medicaid
MDKBC1CHOtherCAREFIRST BCBS
DCS417-0011OtherCAREFIRST BCBS
MD430074296OtherRR MEDICARE