Provider Demographics
NPI:1073875878
Name:STANTON, SHANNON R (BS, MSED)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:R
Last Name:STANTON
Suffix:
Gender:F
Credentials:BS, MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25756 STATE HIGHWAY 10
Mailing Address - Street 2:
Mailing Address - City:WALTON
Mailing Address - State:NY
Mailing Address - Zip Code:13856-2195
Mailing Address - Country:US
Mailing Address - Phone:607-287-2768
Mailing Address - Fax:607-510-4108
Practice Address - Street 1:25756 STATE HIGHWAY 10
Practice Address - Street 2:
Practice Address - City:WALTON
Practice Address - State:NY
Practice Address - Zip Code:13856-2195
Practice Address - Country:US
Practice Address - Phone:607-287-2768
Practice Address - Fax:607-510-4108
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25337174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist