Provider Demographics
NPI:1386196988
Name:KEARNEY, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:KEARNEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MARY
Other - Last Name:COVINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:30 BUCCANEER LN
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-1863
Mailing Address - Country:US
Mailing Address - Phone:631-675-0369
Mailing Address - Fax:
Practice Address - Street 1:30 BUCCANEER LN
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-1863
Practice Address - Country:US
Practice Address - Phone:631-675-0369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-29
Last Update Date:2016-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY315861-1164W00000X
CT34308164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse