Provider Demographics
NPI:1457507717
Name:NICHOLSON, SHANNON LEIGH (CFNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEIGH
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:LEIGH
Other - Last Name:MANGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DNP
Mailing Address - Street 1:19455 DEERFIELD AVE
Mailing Address - Street 2:SUITE 312
Mailing Address - City:LANSDOWNE
Mailing Address - State:VA
Mailing Address - Zip Code:20176-8100
Mailing Address - Country:US
Mailing Address - Phone:703-729-5010
Mailing Address - Fax:703-729-5833
Practice Address - Street 1:19455 DEERFIELD AVE
Practice Address - Street 2:SUITE 312
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-8100
Practice Address - Country:US
Practice Address - Phone:703-729-5010
Practice Address - Fax:703-729-5833
Is Sole Proprietor?:No
Enumeration Date:2008-08-18
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167932363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1457507717Medicaid
VAVV4546AMedicare PIN