Provider Demographics
NPI:1295237477
Name:COULSON, SHANNON (NP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:COULSON
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 1:4106 PORTSMOUTH BLVD # 303
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23701-2968
Mailing Address - Country:US
Mailing Address - Phone:757-393-1136
Mailing Address - Fax:757-698-2499
Practice Address - Street 1:4106 PORTSMOUTH BLVD # 303
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23701-2968
Practice Address - Country:US
Practice Address - Phone:757-393-1136
Practice Address - Fax:757-698-2499
Is Sole Proprietor?:No
Enumeration Date:2018-03-05
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024175887363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology