Healthcare Provider Details

I. General information

NPI: 1689246670
Provider Name (Legal Business Name): SHANNON MARIE HUSTED FNP-BC, MSN, BSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS SHANNON MARIE CLARK

II. Dates (important events)

Enumeration Date: 07/11/2021
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5021 RIVERFRONT DR
SUFFOLK VA
23434-7188
US

IV. Provider business mailing address

5021 RIVERFRONT DR
SUFFOLK VA
23434-7188
US

V. Phone/Fax

Practice location:
  • Phone: 757-319-2423
  • Fax:
Mailing address:
  • Phone: 757-319-2423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13341645-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024185946
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number0001160108
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13341645-8900
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: