Provider Demographics
NPI:1770138406
Name:RUSSELL, SHANNON M
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:RUSSELL
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 1:345 VIGUE RD
Mailing Address - Street 2:
Mailing Address - City:WHITEFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04353-3013
Mailing Address - Country:US
Mailing Address - Phone:207-215-2092
Mailing Address - Fax:
Practice Address - Street 1:345 VIGUE RD
Practice Address - Street 2:
Practice Address - City:WHITEFIELD
Practice Address - State:ME
Practice Address - Zip Code:04353-3013
Practice Address - Country:US
Practice Address - Phone:207-215-2092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERN52456163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse