Provider Demographics
NPI:1952546491
Name:SHANNON, KATHLEEN K (CNM)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:K
Last Name:SHANNON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6300 ODELL RD
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-4107
Mailing Address - Country:US
Mailing Address - Phone:703-801-4093
Mailing Address - Fax:833-694-0324
Practice Address - Street 1:6300 ODELL RD
Practice Address - Street 2:
Practice Address - City:BELTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20705-4107
Practice Address - Country:US
Practice Address - Phone:703-801-4093
Practice Address - Fax:833-694-0324
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-12
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
DCRN1014773367A00000X
MDR179174367A00000X
VA0024167992367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife