Provider Demographics
NPI:1477982965
Name:RITTBERG, SHANNA CONSTANCE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:CONSTANCE
Last Name:RITTBERG
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 YORK AVE
Mailing Address - Street 2:NEUROLOGY/NEUROSURGERY
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065
Mailing Address - Country:US
Mailing Address - Phone:212-639-6920
Mailing Address - Fax:
Practice Address - Street 1:1275 YORK AVE
Practice Address - Street 2:NEUROLOGY/NEUROSURGERY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065
Practice Address - Country:US
Practice Address - Phone:212-639-6920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY30 306495363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1477982965Medicaid