Provider Demographics
NPI:1669138202
Name:SHANNON, DIANE MARIE (REGISTERED NURSE)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:MARIE
Last Name:SHANNON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3438 ROUTE 764
Mailing Address - Street 2:
Mailing Address - City:DUNCANSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16635-7803
Mailing Address - Country:US
Mailing Address - Phone:814-944-7000
Mailing Address - Fax:814-944-5071
Practice Address - Street 1:3438 PA-764
Practice Address - Street 2:
Practice Address - City:DUNCANSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16635
Practice Address - Country:US
Practice Address - Phone:814-944-7000
Practice Address - Fax:814-944-5071
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN510832L163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARN810532LMedicaid