Provider Demographics
NPI:1346012929
Name:PEAK, SHANNON ROBERTSON (FNP-BC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ROBERTSON
Last Name:PEAK
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2137 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-6806
Mailing Address - Country:US
Mailing Address - Phone:434-404-7200
Mailing Address - Fax:
Practice Address - Street 1:2137 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-6806
Practice Address - Country:US
Practice Address - Phone:434-404-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-26
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001298557163WP0200X
VA0024189504363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP0200XNursing Service ProvidersRegistered NursePediatricsGroup - Single Specialty