Provider Demographics
NPI:1578330247
Name:BLOUNT, SHANNON LEIGH
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEIGH
Last Name:BLOUNT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 FAIRFAX AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1912
Mailing Address - Country:US
Mailing Address - Phone:757-446-5600
Mailing Address - Fax:
Practice Address - Street 1:2010 HEALTH CAMPUS DR
Practice Address - Street 2:
Practice Address - City:ROCKINGHAM
Practice Address - State:VA
Practice Address - Zip Code:22801-8679
Practice Address - Country:US
Practice Address - Phone:540-689-1110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0110010197363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program