Provider Demographics
NPI:1609145440
Name:SHANNON, DONNA MARIE (RN01)
Entity Type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:MARIE
Last Name:SHANNON
Suffix:
Gender:F
Credentials:RN01
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 CLAYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-6205
Mailing Address - Country:US
Mailing Address - Phone:631-273-3015
Mailing Address - Fax:
Practice Address - Street 1:186 CLAYWOOD DR
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-6205
Practice Address - Country:US
Practice Address - Phone:631-273-3015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-23
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRN227009-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse