Healthcare Provider Details

I. General information

NPI: 1801403795
Provider Name (Legal Business Name): SHANNON MARIE VANNASANE AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 ERWIN RD
DURHAM NC
27705-4699
US

IV. Provider business mailing address

1306 SILVER DR
MEBANE NC
27302-8942
US

V. Phone/Fax

Practice location:
  • Phone: 919-681-9935
  • Fax:
Mailing address:
  • Phone: 336-260-1078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number5013609
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: