Healthcare Provider Details

I. General information

NPI: 1720994767
Provider Name (Legal Business Name): SHANNON LEE SMITH RN, BSN, PED-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

489 STATE ST
BANGOR ME
04401-6616
US

IV. Provider business mailing address

12 SKYVIEW AVE
BREWER ME
04412-2379
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-8760
  • Fax:
Mailing address:
  • Phone: 207-745-1020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number69303
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: