Provider Demographics
NPI:1114539269
Name:NICOSIA, SHANNON MARIE (FNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:NICOSIA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 HARVEST HILL LN
Mailing Address - Street 2:
Mailing Address - City:SPRING MILLS
Mailing Address - State:PA
Mailing Address - Zip Code:16875-1610
Mailing Address - Country:US
Mailing Address - Phone:814-360-8827
Mailing Address - Fax:
Practice Address - Street 1:200 SCENERY DR
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-7974
Practice Address - Country:US
Practice Address - Phone:570-271-6516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY346354363LF0000X
PASP025407363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily