Healthcare Provider Details

I. General information

NPI: 1154875268
Provider Name (Legal Business Name): SHANNON BURDESHAW CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2016
Last Update Date: 08/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 W 8TH ST APT. 3
WILMINGTON DE
19806-4667
US

IV. Provider business mailing address

1209 W 8TH ST APT. 3
WILMINGTON DE
19806-4667
US

V. Phone/Fax

Practice location:
  • Phone: 256-975-3932
  • Fax:
Mailing address:
  • Phone: 256-975-3932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberCW0000002
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: