Provider Demographics
NPI:1275641144
Name:DUFAULT, SHANNAN K (NPN)
Entity Type:Individual
Prefix:MRS
First Name:SHANNAN
Middle Name:K
Last Name:DUFAULT
Suffix:
Gender:F
Credentials:NPN
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:K
Other - Last Name:TOOLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 751461
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1461
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:1952 LONG GROVE DR STE 202
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-7579
Practice Address - Country:US
Practice Address - Phone:843-971-2992
Practice Address - Fax:843-971-2998
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2139363LP0200X
SC855002080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0832Medicaid
SCAA0549Medicare ID - Type Unspecified
Q20054Medicare UPIN