Provider Demographics
NPI:1770826950
Name:FORD, SHANNON HENNESSY (CPNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:HENNESSY
Last Name:FORD
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 1:4609 PLEASANT GROVE CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-3323
Mailing Address - Country:US
Mailing Address - Phone:919-510-4474
Mailing Address - Fax:
Practice Address - Street 1:1301 FAYETTEVILLE ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-2325
Practice Address - Country:US
Practice Address - Phone:919-956-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-05
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC149601363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics