Provider Demographics
NPI:1578931762
Name:SHANNON, ELIZABETH (PMHNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:SHANNON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14610-2564
Mailing Address - Country:US
Mailing Address - Phone:585-201-8155
Mailing Address - Fax:585-340-7973
Practice Address - Street 1:2300 EAST AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14610-2564
Practice Address - Country:US
Practice Address - Phone:585-201-8155
Practice Address - Fax:585-340-7973
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-04
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF401910-1363LP0808X
NYF401910363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health