Provider Demographics
NPI:1215359708
Name:RENITSKY, SHANNON LYNN (APN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LYNN
Last Name:RENITSKY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:LYNN
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:2 CAPITAL WAY STE 356
Mailing Address - Street 2:
Mailing Address - City:PENNINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08534-2521
Mailing Address - Country:US
Mailing Address - Phone:609-537-6000
Mailing Address - Fax:609-537-6002
Practice Address - Street 1:2 CAPITAL WAY
Practice Address - Street 2:SUITE 356
Practice Address - City:PENNINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08534-2521
Practice Address - Country:US
Practice Address - Phone:609-537-6000
Practice Address - Fax:609-537-6002
Is Sole Proprietor?:No
Enumeration Date:2014-01-17
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP011347363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0409715Medicaid
NJ0409715Medicaid