Provider Demographics
NPI:1578827341
Name:DRAKE, SHANNON VICTORIA
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:VICTORIA
Last Name:DRAKE
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 1:5776 HOWELL RD
Mailing Address - Street 2:
Mailing Address - City:LOCKE
Mailing Address - State:NY
Mailing Address - Zip Code:13092
Mailing Address - Country:US
Mailing Address - Phone:607-423-9304
Mailing Address - Fax:
Practice Address - Street 1:10 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045
Practice Address - Country:US
Practice Address - Phone:607-753-0234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY401477363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health