Provider Demographics
NPI:1053571562
Name:DAVIDSON, SHANNON ROSE (NP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:ROSE
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13332 MIDLOTHIAN TPKE
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-4210
Mailing Address - Country:US
Mailing Address - Phone:804-794-5598
Mailing Address - Fax:804-337-8194
Practice Address - Street 1:3000 WATERCOVE RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3982
Practice Address - Country:US
Practice Address - Phone:804-744-0200
Practice Address - Fax:804-744-8417
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167546363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVJ575A POWMedicare PIN
VAVVJ575C WWWMedicare PIN
VAVVJ575B VIL, WCMedicare PIN