Provider Demographics
NPI:1477575611
Name:KNAGGS, SHANNON B (APRN)
Entity Type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:B
Last Name:KNAGGS
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1951
Mailing Address - Street 2:SAINT RAPHAEL PHYSICIANS
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05302-1951
Mailing Address - Country:US
Mailing Address - Phone:508-595-0531
Mailing Address - Fax:508-829-5367
Practice Address - Street 1:1450 CHAPEL STREET
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511
Practice Address - Country:US
Practice Address - Phone:203-789-4074
Practice Address - Fax:203-867-5534
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001902208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004193116Medicaid
CT500001747Medicare PIN
CTS91042Medicare UPIN