Provider Demographics
NPI:1508299777
Name:CLARK, SHANNON JOAN (AGNP RN)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:JOAN
Last Name:CLARK
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Gender:F
Credentials:AGNP RN
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Mailing Address - Street 1:3031 NEW BERN AVE
Mailing Address - Street 2:STE 306
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-2989
Mailing Address - Country:US
Mailing Address - Phone:919-231-3966
Mailing Address - Fax:919-231-3912
Practice Address - Street 1:3604 BUSH ST
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7511
Practice Address - Country:US
Practice Address - Phone:919-876-7807
Practice Address - Fax:919-876-8823
Is Sole Proprietor?:No
Enumeration Date:2013-08-12
Last Update Date:2021-10-08
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Provider Licenses
StateLicense IDTaxonomies
NC5006374363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner