Provider Demographics
NPI:1689246670
Name:HUSTED, SHANNON MARIE (FNP-BC, MSN, BSN, RN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:HUSTED
Suffix:
Gender:F
Credentials:FNP-BC, MSN, BSN, RN
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5021 RIVERFRONT DR
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-7188
Mailing Address - Country:US
Mailing Address - Phone:757-319-2423
Mailing Address - Fax:
Practice Address - Street 1:5021 RIVERFRONT DR
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-7188
Practice Address - Country:US
Practice Address - Phone:757-319-2423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-11
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13341645-4405363LF0000X
VA0024185946363LF0000X
VA0001160108163WG0000X
VA376J00000X
390200000X
UT13341645-8900363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No376J00000XNursing Service Related ProvidersHomemaker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAT26563035OtherDMV