=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326435264
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEANN MARIE SHANNON M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2015
-----------------------------------------------------
Last Update Date | 08/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1538 KANAWHA BLVD E
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25311-2435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-344-3457
-----------------------------------------------------
Fax | 304-344-3480
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 N HIATUS RD STE 200
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33026-5213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-437-4800
-----------------------------------------------------
Fax | 954-437-6628
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 33617
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | ME145855
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------