Provider Demographics
NPI:1508830548
Name:THOMPSON, SHANNON ANNE (DPM)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:ANNE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:SHANNON
Other - Middle Name:ANNE
Other - Last Name:CONNOLLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:52 CREST AVE
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:MA
Mailing Address - Zip Code:02152-1064
Mailing Address - Country:US
Mailing Address - Phone:617-539-0197
Mailing Address - Fax:617-539-0669
Practice Address - Street 1:52 CREST AVE
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:MA
Practice Address - Zip Code:02152-1064
Practice Address - Country:US
Practice Address - Phone:617-539-0197
Practice Address - Fax:617-539-0669
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 3118213ES0103X
MA2341213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110078988AMedicaid
FLV07337Medicare UPIN
MA110078988AMedicaid
MA000610101Medicare PIN