Provider Demographics
NPI:1962001818
Name:MARTIN, SHANNON NICOLE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 BLACKISTON AVE
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-4304
Mailing Address - Country:US
Mailing Address - Phone:301-268-5594
Mailing Address - Fax:
Practice Address - Street 1:924 SETON DR # C
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-1851
Practice Address - Country:US
Practice Address - Phone:301-797-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR214768363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily