Provider Demographics
NPI:1477974764
Name:HOLDER, SHANNON (DNP, NP-C, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HOLDER
Suffix:
Gender:F
Credentials:DNP, NP-C, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1916 CRAIN HWY S STE 2
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-5565
Mailing Address - Country:US
Mailing Address - Phone:410-762-4550
Mailing Address - Fax:
Practice Address - Street 1:1916 CRAIN HWY S STE 2
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061
Practice Address - Country:US
Practice Address - Phone:410-793-7252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-03
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR170448363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health