Provider Demographics
NPI:1699416354
Name:MARUCCI, SHANNON NICOLE (CRNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:MARUCCI
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 SISTER PIERRE DR STE 407
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-7536
Mailing Address - Country:US
Mailing Address - Phone:410-769-8801
Mailing Address - Fax:
Practice Address - Street 1:1814 BEL AIR RD
Practice Address - Street 2:
Practice Address - City:FALLSTON
Practice Address - State:MD
Practice Address - Zip Code:21047-2734
Practice Address - Country:US
Practice Address - Phone:443-981-3337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-06
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR202904363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics