Provider Demographics
NPI:1396292892
Name:GROVE, SHANNON R (PMHNP-BC)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:R
Last Name:GROVE
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CENTENNIAL DR STE 104
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-2298
Mailing Address - Country:US
Mailing Address - Phone:978-535-1110
Mailing Address - Fax:978-535-2907
Practice Address - Street 1:10 CENTENNIAL DR STE 104
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-2298
Practice Address - Country:US
Practice Address - Phone:978-535-1110
Practice Address - Fax:978-535-2907
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2299385363LP0808X
MA2299385363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA020860Medicaid