Provider Demographics
NPI:1740579952
Name:ANTONELLI, SHANNIELLE
Entity Type:Individual
Prefix:MRS
First Name:SHANNIELLE
Middle Name:
Last Name:ANTONELLI
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 1:600 WASHINGTON AVE
Mailing Address - Street 2:UNIT #A8
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-1100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 HEMINGWAY AVE
Practice Address - Street 2:
Practice Address - City:EAST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06512-3404
Practice Address - Country:US
Practice Address - Phone:203-469-4609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-29
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0011420183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist