Provider Demographics
NPI:1245964782
Name:RUSSELL, SHANNON MCKENZEE (NP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MCKENZEE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6333 CENTER DR BLDG 16
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-4126
Mailing Address - Country:US
Mailing Address - Phone:757-252-9500
Mailing Address - Fax:757-962-9801
Practice Address - Street 1:6333 CENTER DR # 16
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4126
Practice Address - Country:US
Practice Address - Phone:757-252-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-11
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024184645363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care