Provider Demographics
NPI:1477225803
Name:PHILLIPS, SHANNON MARIE (FNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:PHILLIPS
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 1:100 METROPOLITAN PARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-7112
Mailing Address - Country:US
Mailing Address - Phone:315-870-9370
Mailing Address - Fax:315-870-9364
Practice Address - Street 1:357 GENESEE ST
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-2658
Practice Address - Country:US
Practice Address - Phone:315-363-8862
Practice Address - Fax:315-363-5477
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF348042363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily