Provider Demographics
NPI:1770922619
Name:FAIN, SHANNON NICOLE
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:NICOLE
Last Name:FAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:NICOLE
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSWA
Mailing Address - Street 1:4748 COURTNEY LN
Mailing Address - Street 2:APT. H
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-5248
Mailing Address - Country:US
Mailing Address - Phone:919-931-3327
Mailing Address - Fax:
Practice Address - Street 1:200 W PARKVIEW DR
Practice Address - Street 2:SUITE A
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-5958
Practice Address - Country:US
Practice Address - Phone:252-572-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0076911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical