Healthcare Provider Details

I. General information

NPI: 1679155683
Provider Name (Legal Business Name): LORETTA MAREE SHANNON OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 PHYSICIANS DR NW STE 106
SUPPLY NC
28462-4216
US

IV. Provider business mailing address

307 AIRLIE VISTA LN
SURF CITY NC
28445-0109
US

V. Phone/Fax

Practice location:
  • Phone: 910-329-4444
  • Fax: 910-406-4111
Mailing address:
  • Phone: 760-473-1776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2076
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: