Healthcare Provider Details

I. General information

NPI: 1023474251
Provider Name (Legal Business Name): SHANNON TAYLOR SMITH CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2016
Last Update Date: 06/19/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 KEMPSVILLE RD BLDG A
NORFOLK VA
23502-4700
US

IV. Provider business mailing address

601 CHILDRENS LN
NORFOLK VA
23507-1910
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-6550
  • Fax: 757-668-6545
Mailing address:
  • Phone: 757-668-7878
  • Fax: 757-668-7883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0024172592
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: