Provider Demographics
NPI:1659975514
Name:MCDONALD, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2419 BAYVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-4303
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 HARDING AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-5902
Practice Address - Country:US
Practice Address - Phone:631-226-6420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-22
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0465912251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics