Provider Demographics
NPI:1568003879
Name:MILLS, SHANNON JEAN
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:JEAN
Last Name:MILLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:LEONARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14 WALL ST FL 9
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10005-2178
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:259 1ST ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3957
Practice Address - Country:US
Practice Address - Phone:516-663-8312
Practice Address - Fax:516-663-6926
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-08
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024197363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant