Provider Demographics
NPI:1750477238
Name:BAYNE, SHANNON (SPEECH/LANG PATH)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BAYNE
Suffix:
Gender:F
Credentials:SPEECH/LANG PATH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3422 LANCASTER RING ROAD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408
Mailing Address - Country:US
Mailing Address - Phone:540-710-5706
Mailing Address - Fax:
Practice Address - Street 1:600 JACKSON ST
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401
Practice Address - Country:US
Practice Address - Phone:540-373-3223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202003993235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA243017OtherMDIPA
VA036802OtherSENTARA
VA192571OtherANTHEM HEALTHKEEP