Provider Demographics
NPI:1841264322
Name:SHANNON, AMY (APRN)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:SHANNON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:282 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-3322
Mailing Address - Country:US
Mailing Address - Phone:860-545-9100
Mailing Address - Fax:860-545-9095
Practice Address - Street 1:282 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3322
Practice Address - Country:US
Practice Address - Phone:860-545-9100
Practice Address - Fax:860-545-9095
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001745363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004197720Medicaid
CT500001544Medicare ID - Type Unspecified
CT004197720Medicaid