Healthcare Provider Details

I. General information

NPI: 1164598348
Provider Name (Legal Business Name): SHANNON PENICK PRYOR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON PENICK

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 11/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10810 CONNECTICUT AVENUE
KENSINGTON MD
20895-2138
US

IV. Provider business mailing address

2101 E JEFFERSON ST KAISER PERMANENTE MEDICARE ENROLLMENT UNIT
ROCKVILLE MD
20852-4908
US

V. Phone/Fax

Practice location:
  • Phone: 301-929-7100
  • Fax: 301-929-7114
Mailing address:
  • Phone: 301-816-6660
  • Fax: 301-816-6308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License NumberMD33647
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number38383
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberD0053881
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number0101241142
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: