Provider Demographics
NPI:1598598690
Name:SHANAHAN, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:SHANAHAN
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 1:1 BROOKLINE PL STE 225
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-7294
Mailing Address - Country:US
Mailing Address - Phone:857-307-4400
Mailing Address - Fax:857-307-4414
Practice Address - Street 1:1 BROOKLINE PL STE 225
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-7294
Practice Address - Country:US
Practice Address - Phone:857-307-4400
Practice Address - Fax:857-307-4414
Is Sole Proprietor?:No
Enumeration Date:2024-08-23
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2379864363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care