Individual
MS. SHANNON R RUSSOM
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
N.P.
Contact information
Practice address
353 BLAIR PARK RD, WILLISTON, VT 05495-7530
(802) 847-1600
(802) 847-7184
Mailing address
87 CARSE RD, HUNTINGTON, VT 05462-9550
(802) 434-4195
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
1010017858
VT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1008958
—
VT
01
—
150268
MVP
VT
01
—
58796
BLUE SHIELD
VT
01
—
6309101
APEX
VT
Enumeration date
07/06/2006
Last updated
07/08/2007
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