Provider Demographics
NPI:1114364387
Name:CAVEDINE, SHANNON (PMHNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:CAVEDINE
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3258 GREENLEAFE DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:NY
Mailing Address - Zip Code:13135-1539
Mailing Address - Country:US
Mailing Address - Phone:315-391-3242
Mailing Address - Fax:
Practice Address - Street 1:110 W 6TH ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2507
Practice Address - Country:US
Practice Address - Phone:315-326-3555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-29
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY388737163WP0808X
NY401603363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health