1447756416 NPI number — DR. SHANNON MARIE WENTWORTH MD

Table of content: DR. SHANNON MARIE WENTWORTH MD (NPI 1447756416)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447756416 NPI number — DR. SHANNON MARIE WENTWORTH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WENTWORTH
Provider First Name:
SHANNON
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447756416
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2041 GEORGIA AVENUE NW, SUITE 3400
Provider Second Line Business Mailing Address:
HOWARD UNIVERSITY FACULTY PRACTICE PLAN
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
DC
Provider Business Mailing Address Postal Code:
20060-1502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
202-865-6679
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2041 GEORGIA AVENUE NW
Provider Second Line Business Practice Location Address:
FIRST FLOOR, SUITE B
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20060-2006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-865-6679
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/30/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  MD210002010 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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