Provider Demographics
NPI:1902386782
Name:THAIN, SHANNON CANTRICE (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:CANTRICE
Last Name:THAIN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7068
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-0068
Mailing Address - Country:US
Mailing Address - Phone:757-481-2515
Mailing Address - Fax:757-481-4064
Practice Address - Street 1:1168 FIRST COLONIAL RD STE 101
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2444
Practice Address - Country:US
Practice Address - Phone:757-481-2515
Practice Address - Fax:757-481-4064
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024176347363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily