Healthcare Provider Details

I. General information

NPI: 1336057595
Provider Name (Legal Business Name): SHANNON OLEXA-FOWLER CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 RIDGELY AVE STE 222
ANNAPOLIS MD
21401-1073
US

IV. Provider business mailing address

15 OVERLOOK DR
PRINCE FREDERICK MD
20678-4308
US

V. Phone/Fax

Practice location:
  • Phone: 410-266-8049
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR239349
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: