Healthcare Provider Details

I. General information

NPI: 1346314739
Provider Name (Legal Business Name): SHANNON RENEE BLACKMER M. D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 LOFTIS BLVD STE 101
NEWPORT NEWS VA
23606-2999
US

IV. Provider business mailing address

11712 JEFFERSON AVE # 763
NEWPORT NEWS VA
23606-4406
US

V. Phone/Fax

Practice location:
  • Phone: 757-596-7938
  • Fax:
Mailing address:
  • Phone: 612-280-2767
  • Fax: 612-665-8564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number0101250670
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: