Provider Demographics
NPI:1093469744
Name:KELLY, SHANNON CATHLEEN (APN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:CATHLEEN
Last Name:KELLY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 RTE 37 W STE 104
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755-8050
Mailing Address - Country:US
Mailing Address - Phone:732-240-1100
Mailing Address - Fax:
Practice Address - Street 1:601 ROUTE 37 W STE 104
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-8050
Practice Address - Country:US
Practice Address - Phone:732-240-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-10
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR01268700363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care