Provider Demographics
NPI:1770128662
Name:THORNHILL, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:THORNHILL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 GRANDON LOOP RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BCH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-3517
Mailing Address - Country:US
Mailing Address - Phone:757-373-6692
Mailing Address - Fax:
Practice Address - Street 1:2025 GRANDON LOOP RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BCH
Practice Address - State:VA
Practice Address - Zip Code:23456-3517
Practice Address - Country:US
Practice Address - Phone:757-373-6692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02020128962255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer