Provider Demographics
NPI:1275641144
Name:TOOLE DUFAULT, SHANNAN KARLAYNE (NPN)
Entity type:Individual
Prefix:MRS
First Name:SHANNAN
Middle Name:KARLAYNE
Last Name:TOOLE DUFAULT
Suffix:
Gender:F
Credentials:NPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 RIVERTOWNE COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-8700
Mailing Address - Country:US
Mailing Address - Phone:843-270-5902
Mailing Address - Fax:
Practice Address - Street 1:2016 1ST AVE
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-0408
Practice Address - Country:US
Practice Address - Phone:843-873-4545
Practice Address - Fax:843-873-1561
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2139363LP0200X
SC855002080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0832Medicaid
SCAA0549Medicare ID - Type Unspecified
Q20054Medicare UPIN