Provider Demographics
NPI:1164679080
Name:SHANNON, ELIZABETH C
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:C
Last Name:SHANNON
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 1:226 N BALLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTIA
Mailing Address - State:NY
Mailing Address - Zip Code:12302-2543
Mailing Address - Country:US
Mailing Address - Phone:518-370-2252
Mailing Address - Fax:
Practice Address - Street 1:6021 STATEFARM RD
Practice Address - Street 2:
Practice Address - City:GUILDERLAND
Practice Address - State:NY
Practice Address - Zip Code:12084
Practice Address - Country:US
Practice Address - Phone:518-456-6525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-21
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196924163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health