Provider Demographics
NPI:1295366672
Name:MCKINNEY, SHANNON ROSE
Entity Type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:ROSE
Last Name:MCKINNEY
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 1:1369 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10018-7200
Mailing Address - Country:US
Mailing Address - Phone:212-268-8830
Mailing Address - Fax:
Practice Address - Street 1:1369 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-7200
Practice Address - Country:US
Practice Address - Phone:212-268-8830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker