Provider Demographics
NPI:1639894165
Name:FOLEY, SHANNON JEAN (NP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:JEAN
Last Name:FOLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11702 ASSATEAGUE RD
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-2416
Mailing Address - Country:US
Mailing Address - Phone:443-235-3451
Mailing Address - Fax:
Practice Address - Street 1:9748 STEPHEN DECATUR HWY STE 104
Practice Address - Street 2:
Practice Address - City:OCEAN CITY
Practice Address - State:MD
Practice Address - Zip Code:21842-9358
Practice Address - Country:US
Practice Address - Phone:410-390-5954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-06
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELP-0010585363LA2200X
MDR140287363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR140287OtherMARYLAND LICENSE
DE0125008OtherPVS SECURITY CODE
DELP0010585OtherNURSE PRACTITIONER LICENSE