Provider Demographics
NPI:1649594920
Name:FADGEN, SHANNA S (LPN)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:S
Last Name:FADGEN
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 1:347 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14604-2617
Mailing Address - Country:US
Mailing Address - Phone:585-454-4930
Mailing Address - Fax:585-325-6059
Practice Address - Street 1:347 EAST AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14604-2617
Practice Address - Country:US
Practice Address - Phone:585-454-4930
Practice Address - Fax:585-325-6059
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-16
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY293186164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse