Provider Demographics
NPI:1558603977
Name:WISE, SHANNON PAIGE (CNM)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:PAIGE
Last Name:WISE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 FORT EVANS RD NE
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-4420
Mailing Address - Country:US
Mailing Address - Phone:703-443-2000
Mailing Address - Fax:703-443-2033
Practice Address - Street 1:163 FORT EVANS RD NE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-4420
Practice Address - Country:US
Practice Address - Phone:703-443-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-24
Last Update Date:2025-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024170771367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife