Provider Demographics
NPI:1598072464
Name:SMITH, SHANNON PAULINE (LPN)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:PAULINE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 FITCH AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-4708
Mailing Address - Country:US
Mailing Address - Phone:315-283-7693
Mailing Address - Fax:
Practice Address - Street 1:36 FITCH AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-4708
Practice Address - Country:US
Practice Address - Phone:315-283-7693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-13
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY270337-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse