Provider Demographics
NPI:1346314739
Name:BLACKMER, SHANNON RENEE (M D)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:RENEE
Last Name:BLACKMER
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 TUCKER DR
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3573
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:NMRTC, DIRECTORATE OF PUBLIC HEALTH SERVICES
Practice Address - Street 2:620 JOHN PAUL JONES CIRCLE
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708
Practice Address - Country:US
Practice Address - Phone:757-953-0613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA97553208D00000X
VA01012506702083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice