Healthcare Provider Details

I. General information

NPI: 1932437142
Provider Name (Legal Business Name): SHANNON RENEE SEGRES YORKMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2009
Last Update Date: 06/04/2020
Certification Date: 06/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE ST
BALTIMORE MD
21287-4965
US

IV. Provider business mailing address

63 HORSEMAN CT
RANDALLSTOWN MD
21133-4065
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-1675
  • Fax:
Mailing address:
  • Phone: 443-392-7572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR161384
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: