Provider Demographics
NPI:1629397724
Name:LOWE, SHANNON (QRP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:LOWE
Suffix:
Gender:F
Credentials:QRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3609 E CUMBERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-5113
Mailing Address - Country:US
Mailing Address - Phone:304-327-6105
Mailing Address - Fax:304-327-6107
Practice Address - Street 1:3609 E CUMBERLAND RD
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-5113
Practice Address - Country:US
Practice Address - Phone:304-327-6105
Practice Address - Fax:304-327-6107
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-28
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVQRP00000265171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVQRP00000265OtherBRICKSTREET INSURACE UPIN