Provider Demographics
NPI:1689929747
Name:BAXTER, SHANNON J (LPN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:J
Last Name:BAXTER
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 1:723 HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-1938
Mailing Address - Country:US
Mailing Address - Phone:315-432-5636
Mailing Address - Fax:
Practice Address - Street 1:723 HICKORY ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1938
Practice Address - Country:US
Practice Address - Phone:315-432-5636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305023-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse