Provider Demographics
NPI:1255705281
Name:MILLER, SHANNON MCDONNELL (FNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MCDONNELL
Last Name:MILLER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:ASHLEY
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 79777
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-0777
Mailing Address - Country:US
Mailing Address - Phone:434-654-7794
Mailing Address - Fax:434-654-7752
Practice Address - Street 1:29 JEFFERSON CT
Practice Address - Street 2:
Practice Address - City:ZION CROSSROADS
Practice Address - State:VA
Practice Address - Zip Code:22942-9602
Practice Address - Country:US
Practice Address - Phone:434-654-8900
Practice Address - Fax:540-832-1728
Is Sole Proprietor?:No
Enumeration Date:2015-11-13
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001226713163W00000X
VA0024174550363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVN792AMedicare PIN