Provider Demographics
NPI:1609818038
Name:MCCARTHY, SHAUNA (CNP)
Entity Type:Individual
Prefix:
First Name:SHAUNA
Middle Name:
Last Name:MCCARTHY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:SHAUNA
Other - Middle Name:
Other - Last Name:DIEFENDERFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:63 BRYNMAWR DR
Mailing Address - Street 2:
Mailing Address - City:EAST LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01028-3012
Mailing Address - Country:US
Mailing Address - Phone:413-525-0701
Mailing Address - Fax:413-439-0096
Practice Address - Street 1:103 MYRON ST
Practice Address - Street 2:SUITE A
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089
Practice Address - Country:US
Practice Address - Phone:413-592-1980
Practice Address - Fax:413-439-0100
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA201898363L00000X
MARN201898363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP02675Medicare UPIN
MANP2233Medicare ID - Type Unspecified