Provider Demographics
NPI:1699398495
Name:GORMAN, SHANNON (CPNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:GORMAN
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1137 MILLER AVE
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08030-1326
Mailing Address - Country:US
Mailing Address - Phone:609-923-7880
Mailing Address - Fax:
Practice Address - Street 1:856 S WHITE HORSE PIKE UNIT 2
Practice Address - Street 2:
Practice Address - City:HAMMONTON
Practice Address - State:NJ
Practice Address - Zip Code:08037-2032
Practice Address - Country:US
Practice Address - Phone:609-704-8848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP021825363LP0200X
NJ26NJ01032000363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics