Provider Demographics
NPI:1538836366
Name:DESMOND, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:DESMOND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5121 STAVERLY LN
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-1786
Mailing Address - Country:US
Mailing Address - Phone:770-655-2145
Mailing Address - Fax:
Practice Address - Street 1:3024 NEW BERN AVE # 102
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1247
Practice Address - Country:US
Practice Address - Phone:919-350-7331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-28
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN257653163W00000X
GA725367367500000X
NC725367367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse