Provider Demographics
NPI:1538885686
Name:MAIN, SHANNON MARIE (PMHNP, CNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:MAIN
Suffix:
Gender:F
Credentials:PMHNP, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:75 SYLVAN ST BLDG C
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-2763
Mailing Address - Country:US
Mailing Address - Phone:978-619-6850
Mailing Address - Fax:978-961-6339
Practice Address - Street 1:75 SYLVAN ST BLDG C
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-2763
Practice Address - Country:US
Practice Address - Phone:978-406-4164
Practice Address - Fax:978-587-3220
Is Sole Proprietor?:No
Enumeration Date:2022-10-19
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH071196-21163W00000X
MACNPNE10000313363LP0808X
MARN2298619163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse