Provider Demographics
NPI:1093453078
Name:ELLIS LYONS, SHANAKAYE
Entity Type:Individual
Prefix:
First Name:SHANAKAYE
Middle Name:
Last Name:ELLIS LYONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 E AVON DR
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2023
Mailing Address - Country:US
Mailing Address - Phone:646-417-3241
Mailing Address - Fax:
Practice Address - Street 1:21 E AVON DR
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2023
Practice Address - Country:US
Practice Address - Phone:646-417-3241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-20
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343771164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse