Provider Demographics
NPI:1497994958
Name:REA, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:REA
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 1:343 101ST ST
Mailing Address - Street 2:APT. 6F
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-8240
Mailing Address - Country:US
Mailing Address - Phone:631-790-5396
Mailing Address - Fax:
Practice Address - Street 1:2223 FOREST AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310
Practice Address - Country:US
Practice Address - Phone:212-947-5770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-06
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0071081171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor