Provider Demographics
NPI:1366507329
Name:SHANNON, CATHERINE MARY (FNP)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:MARY
Last Name:SHANNON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 ISLAND PKWY
Mailing Address - Street 2:
Mailing Address - City:ISLAND PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11558-1403
Mailing Address - Country:US
Mailing Address - Phone:631-862-3541
Mailing Address - Fax:631-862-3717
Practice Address - Street 1:50 ROUTE 25A
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-1348
Practice Address - Country:US
Practice Address - Phone:631-862-3541
Practice Address - Fax:631-862-3717
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF 332622363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP16998Medicare UPIN