Provider Demographics
NPI:1295828499
Name:MUNRO, SHANNON C (NP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:C
Last Name:MUNRO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:DOUGHTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:37 PALMER ST STE 3
Mailing Address - Street 2:
Mailing Address - City:CALAIS
Mailing Address - State:ME
Mailing Address - Zip Code:04619-1341
Mailing Address - Country:US
Mailing Address - Phone:207-454-8195
Mailing Address - Fax:
Practice Address - Street 1:37 PALMER ST STE 3
Practice Address - Street 2:
Practice Address - City:CALAIS
Practice Address - State:ME
Practice Address - Zip Code:04619-1341
Practice Address - Country:US
Practice Address - Phone:207-454-8195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELS7243104100000X
MEAP081371363LF0000X
MER049265363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431935199Medicaid
NP5133Medicare ID - Type Unspecified
Q52698Medicare UPIN
MEUX8672Medicare PIN