Healthcare Provider Details

I. General information

NPI: 1245240969
Provider Name (Legal Business Name): JOANNA WOLICKI-SHANNON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 10/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 NORTH QUEEN STREET
KINSTON NC
28501-1581
US

IV. Provider business mailing address

1305 NORTH QUEEN STREET
KINSTON NC
28501-1581
US

V. Phone/Fax

Practice location:
  • Phone: 252-523-2781
  • Fax: 252-523-2711
Mailing address:
  • Phone: 252-523-2781
  • Fax: 252-523-2711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number200001033
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: