Healthcare Provider Details

I. General information

NPI: 1417744103
Provider Name (Legal Business Name): SHANNON M WALKER CCMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2025
Last Update Date: 04/24/2025
Certification Date: 04/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 7TH ST STE 104
PORTSMOUTH VA
23704-4800
US

IV. Provider business mailing address

100 7TH ST STE 104
PORTSMOUTH VA
23704-4800
US

V. Phone/Fax

Practice location:
  • Phone: 757-330-5248
  • Fax: 757-330-5290
Mailing address:
  • Phone: 757-330-5248
  • Fax: 757-330-5290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License NumberCCMA-2262
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: