Provider Demographics
NPI:1053713453
Name:AVERY-DESMARAIS, SHANNON L (MSN, NP-C)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:L
Last Name:AVERY-DESMARAIS
Suffix:
Gender:F
Credentials:MSN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:200 MILL RD STE 180
Mailing Address - Street 2:
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5255
Mailing Address - Country:US
Mailing Address - Phone:508-973-2000
Mailing Address - Fax:508-973-2001
Practice Address - Street 1:827 AMERICAN LEGION HWY
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:MA
Practice Address - Zip Code:02790-4128
Practice Address - Country:US
Practice Address - Phone:508-636-5101
Practice Address - Fax:508-636-3651
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MARN269120363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110101239AMedicaid
MAS400169971Medicare PIN