Provider Demographics
NPI:1891756037
Name:SCOLARO, SHANNON L (NP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:SCOLARO
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 MASSACHUSETTS AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2690
Mailing Address - Country:US
Mailing Address - Phone:617-414-4505
Mailing Address - Fax:
Practice Address - Street 1:235 N PEARL ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1794
Practice Address - Country:US
Practice Address - Phone:508-427-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA212661363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP2812OtherBLUE CROSS
MA0391841Medicaid
MA39159OtherHARVARD PILGRIM
MANP2812OtherBLUE CROSS
MANP2812Medicare ID - Type Unspecified