Provider Demographics
NPI:1477040285
Name:KANNENGEISER, SHANNA
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:
Last Name:KANNENGEISER
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 1:2475 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-3227
Mailing Address - Country:US
Mailing Address - Phone:516-384-0218
Mailing Address - Fax:
Practice Address - Street 1:2475 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783-3227
Practice Address - Country:US
Practice Address - Phone:516-384-0218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY859930141171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator