Provider Demographics
NPI:1215403704
Name:CALLE, SHANNON M
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:CALLE
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 1:329 E 149TH ST FL 4
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-5626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3660 WALDO AVE APT 6C
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-2231
Practice Address - Country:US
Practice Address - Phone:845-661-3704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2424284OtherTEACHERS