Provider Demographics
NPI:1477233203
Name:PETTY, SHANNON NAYMON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:NAYMON
Last Name:PETTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 N VEITCH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22201-3423
Mailing Address - Country:US
Mailing Address - Phone:571-215-4515
Mailing Address - Fax:
Practice Address - Street 1:2041 MARTIN LUTHER KING JR AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-7024
Practice Address - Country:US
Practice Address - Phone:202-547-8450
Practice Address - Fax:202-610-7147
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-18
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator