Healthcare Provider Details

I. General information

NPI: 1497562433
Provider Name (Legal Business Name): ABIGAIL MARIE SHANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ABBIE SHANNON

II. Dates (important events)

Enumeration Date: 12/13/2024
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2095 HENRY TECKLENBURG DR
CHARLESTON SC
29414-5733
US

IV. Provider business mailing address

PO BOX 632509
CINCINNATI OH
45263-2508
US

V. Phone/Fax

Practice location:
  • Phone: 843-402-1000
  • Fax:
Mailing address:
  • Phone: 803-765-1838
  • Fax: 803-765-1732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number200686
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number32247
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: