Healthcare Provider Details

I. General information

NPI: 1407686553
Provider Name (Legal Business Name): SHANNON GENEVIEVE GREENE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2024
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2125 LANGHORNE RD STE 303
LYNCHBURG VA
24501-1423
US

IV. Provider business mailing address

2125 LANGHORNE RD STE 301
LYNCHBURG VA
24501-1423
US

V. Phone/Fax

Practice location:
  • Phone: 434-200-3600
  • Fax:
Mailing address:
  • Phone: 434-200-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110010405
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: