Provider Demographics
NPI:1417322926
Name:MARTIN, SHANNON NICOLE (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:NICOLE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406B CRAIN HWY S STE 304
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-4094
Mailing Address - Country:US
Mailing Address - Phone:301-804-0344
Mailing Address - Fax:
Practice Address - Street 1:1406B CRAIN HWY S STE 304
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-4094
Practice Address - Country:US
Practice Address - Phone:301-804-0344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-09
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR182264363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily