Provider Demographics
NPI:1871102277
Name:ULLMAN, SHANNON MILLER (APRN-CNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MILLER
Last Name:ULLMAN
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:KEATS
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13 EASTERN TRL
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-5991
Mailing Address - Country:US
Mailing Address - Phone:845-863-5504
Mailing Address - Fax:
Practice Address - Street 1:489 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-2825
Practice Address - Country:US
Practice Address - Phone:304-622-2708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-31
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV106952363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily