Provider Demographics
NPI:1487953675
Name:EVANS, SHANNON KELLY
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:KELLY
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:111 COLCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-1473
Mailing Address - Country:US
Mailing Address - Phone:802-847-2700
Mailing Address - Fax:
Practice Address - Street 1:4123 DUTCHMANS LN STE 301
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4721
Practice Address - Country:US
Practice Address - Phone:802-847-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-28
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042.0012902208000000X
390200000X
KY502182080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program