Healthcare Provider Details

I. General information

NPI: 1114177458
Provider Name (Legal Business Name): SHANNON T PARKER M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHANNON RENEE' TYNCH

II. Dates (important events)

Enumeration Date: 09/23/2008
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 EDENTON ROAD ST
HERTFORD NC
27944-8209
US

IV. Provider business mailing address

366 DANIELS RD
CORAPEAKE NC
27926-9699
US

V. Phone/Fax

Practice location:
  • Phone: 252-426-5741
  • Fax:
Mailing address:
  • Phone: 252-339-2835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number12106895
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: