Provider Demographics
NPI:1194363457
Name:SHANAHAN, SHIANNE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:SHIANNE
Middle Name:
Last Name:SHANAHAN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 W RIVER RD
Mailing Address - Street 2:
Mailing Address - City:NICHOLS
Mailing Address - State:NY
Mailing Address - Zip Code:13812-2109
Mailing Address - Country:US
Mailing Address - Phone:607-972-9138
Mailing Address - Fax:
Practice Address - Street 1:9768 LIBERTY DR
Practice Address - Street 2:
Practice Address - City:PAINTED POST
Practice Address - State:NY
Practice Address - Zip Code:14870-9094
Practice Address - Country:US
Practice Address - Phone:607-937-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-18
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045351-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist