Basic Information
| Provider Information | |||||||||
| NPI: | 1821099110 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULLERTON | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | DEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 141 LONGWATER DR | ||||||||
| Address2: | |||||||||
| City: | NORWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020611632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818785200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 51 PERFORMANCE DR | ||||||||
| Address2: | ENTRY 2 | ||||||||
| City: | WEYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021893141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7816828000 | ||||||||
| FaxNumber: | 7813351412 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 01/08/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 205500 | MA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 042297845 | 01 | UNITED HEALTH CARE | OTHER | 042297845 | 01 | MULTI-PLAN/PHCS | OTHER | 1821099110 | 01 | NEIGHBORHOOD HEALTH PLAN | OTHER | 205500 | 01 | TUFTS/TMP | OTHER | AA279482 | 01 | HARVARD PILGRIM | OTHER | 042297845 | 01 | GIC/UNICARE | OTHER | 042297845 | 01 | TRICARE | OTHER | 042297845 | 01 | HCVM/FIRST HEALTH/COVENTRY | OTHER | 9034507 | 01 | CIGNA | OTHER | 976196 08 | 01 | NETWORK HEALTH | OTHER | 1821099110 | 05 | MA | MEDICAID | 1821099110 | 01 | FALLON | OTHER | 7151128 | 01 | AETNA | OTHER | SS0128 | 01 | BCBSMA | OTHER |