Provider Demographics
NPI:1942291653
Name:BEAUSOLEIL, SHANNON B I (MD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:B
Last Name:BEAUSOLEIL
Suffix:I
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 FARMINGTON AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2673
Mailing Address - Country:US
Mailing Address - Phone:860-236-0331
Mailing Address - Fax:860-263-8697
Practice Address - Street 1:1216 FARMINGTON AVE STE 202
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2673
Practice Address - Country:US
Practice Address - Phone:860-236-0331
Practice Address - Fax:860-263-8697
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT043733207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3352025OtherAETNA
MA1302469Medicaid
MA218498OtherCONNECTICARE
MA218498OtherCONNECTICARE
CTA36200Medicare PIN