Healthcare Provider Details

I. General information

NPI: 1508830548
Provider Name (Legal Business Name): SHANNON ANNE THOMPSON DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHANNON ANNE CONNOLLY DPM

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 03/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 CREST AVE
WINTHROP MA
02152-1064
US

IV. Provider business mailing address

52 CREST AVE
WINTHROP MA
02152-1064
US

V. Phone/Fax

Practice location:
  • Phone: 617-539-0197
  • Fax: 617-539-0669
Mailing address:
  • Phone: 617-539-0197
  • Fax: 617-539-0669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO 3118
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number2341
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: