Provider Demographics
NPI:1477913903
Name:MARTIN, SHANNON E (FNP-BC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:E
Last Name:MARTIN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 ROUTE 36
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC HIGHLANDS
Mailing Address - State:NJ
Mailing Address - Zip Code:07716-2469
Mailing Address - Country:US
Mailing Address - Phone:732-291-3865
Mailing Address - Fax:
Practice Address - Street 1:1012 ROUTE 36
Practice Address - Street 2:
Practice Address - City:ATLANTIC HIGHLANDS
Practice Address - State:NJ
Practice Address - Zip Code:07716-2469
Practice Address - Country:US
Practice Address - Phone:732-291-3865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-25
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00620300363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0018104Medicaid