Provider Demographics
NPI:1467445924
Name:IDZIK, SHANNON K (CRNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:K
Last Name:IDZIK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:K
Other - Last Name:REEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:655 W LOMBARD ST
Mailing Address - Street 2:345
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1512
Mailing Address - Country:US
Mailing Address - Phone:410-706-8129
Mailing Address - Fax:410-706-0344
Practice Address - Street 1:655 W LOMBARD ST
Practice Address - Street 2:345
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1512
Practice Address - Country:US
Practice Address - Phone:410-706-8129
Practice Address - Fax:410-706-0344
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR131534363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q19895Medicare UPIN