=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295281806
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON GREEN MCCORMICK APRN, CFCP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2016
-----------------------------------------------------
Last Update Date | 09/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4612 S. CLAIBORNE AVE.
-----------------------------------------------------
City | NEW ORLEANS
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-496-0212
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4612 S CLAIBORNE AVE
-----------------------------------------------------
City | NEW ORLEANS
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70125-5010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-496-0212
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WW0101X
-----------------------------------------------------
Taxonomy Name | Ambulatory Women's Health Care Registered Nurse
-----------------------------------------------------
License Number | 71607
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LW0102X
-----------------------------------------------------
Taxonomy Name | Women's Health Nurse Practitioner
-----------------------------------------------------
License Number | 204160
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------