Healthcare Provider Details

I. General information

NPI: 1447877352
Provider Name (Legal Business Name): SHANNON BARNICLE PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2020
Last Update Date: 04/15/2022
Certification Date: 04/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 FORE RIVER PKWY
PORTLAND ME
04102-2779
US

IV. Provider business mailing address

175 FORE RIVER PKWY
PORTLAND ME
04102-2779
US

V. Phone/Fax

Practice location:
  • Phone: 207-553-6105
  • Fax:
Mailing address:
  • Phone: 207-553-6105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP211398
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: