MEDICARE: SHANNON MARIE BROWN ATC, LAT, MS, CPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1043963309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON MARIE BROWN ATC, LAT, MS, CPT

Provider Business Mailing Address
First Line	:	11710 FAIRFAX WOODS WAY APT 21305
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22030-8334
Country	:	US
Telephone Number	:	804-832-0972
Fax Number	:

Provider Business Practice Location Address
First Line	:	11204 BRADDOCK RD
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22030-5405
Country	:	US
Telephone Number	:	804-832-0972
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/27/2022
Last Update Date	:	12/21/2022

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