Provider Demographics
NPI:1629787916
Name:DENISOFF, SHANNON MARLENE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARLENE
Last Name:DENISOFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:713 TROY SCHENECTADY RD STE 131
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2490
Practice Address - Country:US
Practice Address - Phone:518-713-4434
Practice Address - Fax:518-713-4432
Is Sole Proprietor?:No
Enumeration Date:2022-11-16
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY745562163W00000X
NYF31114401363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse