Provider Demographics
NPI:1275678484
Name:AXELSON, SHANNON S (CNM MSN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:S
Last Name:AXELSON
Suffix:
Gender:F
Credentials:CNM MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 MEDICAL CENTER PKWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-8160
Mailing Address - Country:US
Mailing Address - Phone:207-621-9100
Mailing Address - Fax:207-623-1462
Practice Address - Street 1:35 MEDICAL CENTER PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-8160
Practice Address - Country:US
Practice Address - Phone:207-621-9100
Practice Address - Fax:207-623-1462
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER047004176B00000X
MECNM82054367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME269350099Medicaid
MM7365Medicare PIN